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LAGUARDIA COMMUNITY COLLEGE CITY UNIVERSITY OF New York DEPARTMENT OF NATURAL & APPLIED SCIENCE PRACTICAL NURSING PROGRAM Documentation of the Nursing Process Student’s name: Anaise Ikama Date: October 18, 07 Client’s Initial: C. Instructor: H. Mckenize Admitted Medical Diagnosis: OB Labor Client’s Objectives (s): Client will regain normal urinary elimination patterns within 2 hours after childbirth, demonstrate ability to wipe from front to back by the second day of postpartum, and verbalize signs and symptoms of urinary tract infection to report before being discharge from postpartum. Assessment Gravida: 4 Para: 0030 EDC: 10/23/07 LMP: 1/16/07 EGA: 38 weeks + 1 day Nursing Diagnosis 1. Impaired Urinary Elimination related to anesthesia as evidenced by diminished bladder tone and sensation Outcome evaluation a. Client will regain normal urinary elimination patterns within 2 hours after childbirth Admitted vital signs: T: 97 F P: 101 BP: 135/81 Pelvic exam:2-3/70/-2/I Contractions were 1.5 2. Risk for infection a. Client will Nursing Intervention a. Assess for bladder distension whenever fundal height is checked after childbirth Rationales a. Assessment provides information about bladder distension b. Encourage client to void every 2 to 3 hours after birth by assisting client to bathroom if possible, or to sit on bedpan. b. To prevent distension of bladder which interfere with uterine contraction and may cause hemorrhage (atony). a. Teach client to wash a. Teaching provides minute in length related to laceration approximately 5 minute during delivery as apart. evidenced by Patient had a second degree laceration Meds: Lidocaine was given to suppress the pain demonstrate ability to wipe from front to back by the second day of postpartum hands before and after using the bathroom and to wipe and apply peripads front to back b. client will verbalize signs and symptoms of urinary tract infection to report before being discharge from postpartum b. Teach client signs and symptoms of urinary tract infection to report to care giver: frequency, urgency, burning or pain with urination. 3. Risk for constipation related to laceration during childbirth as evidenced by fear of stitches disruption a. Assess usual bowel pattern and date of last bowel movement a. Client will obtain relief of constipation within Inform client that the bowels tend to be sluggish after childbirth due to decrease in muscle tone, dehydration and lack of food during labor Reassure client that a bowel movement is not going to disrupt her stitches information the client needs to avoid the introduction of pathogens into the urinary tract. a. To provide information about normal bowel habits and current peristaltic activity Client may be expected to have daily bowel movement Client may be fearful of damaging perineal incisions or experiencing great pain b. client will verbalize the importance of fibers and fluid in her diet to prevent constipation b. Instruct client to stimulate bowel mobility by eating fiber, fresh fruits and vegetables, drinking 8 to 10 glasses of fluids per day with passage of stool b. Client may be unfamiliar with information and may find new motivation to improve diet to prevent constipation