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Assessment
Subjective Data:
 Pt. is 35 y/o African American
female transferred to M/B unit
on 11/5/13.
 Transferred following lower
transverse C-section
performed in response to nonreassuring FHT and FTP 2º
CPD.
 OB Hx.:
o GP: 2/0
o GTPAL: 2/0/0/1/0
 Gestational age (at delivery):
38 weeks
o LMP: 2/12/13
o EDB: 11/19/13
 Hx. of Gestational DM & HTN,
physiologic anemia (during
pregnancy), and substance
abuse (cocaine & marijuana).
 Estimated blood loss during
C/S is 800 mL
 No episiotomy performed on
mother while in labor. No
cervical lacerations.
 BP prior to delivery: 126/70
 Labs (before/after delivery)
o Hgb: 12.5 N / 10.7 
o Hct: 36 N / 31.5 
 Medications administered
during labor: Bupivacaine
(epidural), Duramorph IVP,
Pitocin IVPB
 Pitocin IVPB also administered
on L&D during immediate
recovery period following C/S
 Current medications:
Diagnosis/Plan
Dx: Risk for bleeding
Interventions
Evaluation
1. Immediately following
Outcomes:
delivery, initiate a 20-unit
1. Fundus remained firm, midline,
R/T: stretching of birth canal and
bolus of Pitocin IVPB. Also
and about the size of an orange
transverse lower uterine incision
administer other oxytocic
upon each assessment. Initial
drugs (i.e. Methergine, Cytotec,
fundal height was at 1
2º: labor and Caesarean section
Hemabate) per MD orders.
fingerbreadth below the
Rationale: Pitocin and other
umbilicus. Upon final
oxytocic agents stimulate
assessment of shift (16:00),
Goal: Pt. will remain free of S&S
contraction of the uterus, which
fundal height was at 2
postpartal hemorrhage and will
compresses the maternal vessels
fingerbreadths below the
maintain adequate fluid volume to
and reduces the risk of
umbilicus.
promote adequate tissue perfusion
postpartal hemorrhage.
2. Small amount of lochia rubra
and bodily function from time of
reported by night nurse. All
delivery until the end of the
2. After delivery, administer IVF
assessments during this shift
second postpartal day.
(i.e. LR) per MD orders.
showed scant amount of lochia
Encourage
oral
fluid
intake.
rubra. Mild fleshy odor
AEB:
Rationale: IV and oral fluids
present.
1. Fundus firm, midline, and
help
to
replace
fluid
lost
during
3.
Ranges of VS for this shift
demonstrates proper
labor and C/S and help to
(min–max) were as follows:
involution progress.
restore
blood
volume.
2. Decrease in amount of lochia
 Temp: 98.3-98.7
and absence of foul odor.
 Pulse: 75-86
3.
Palpate
the
mother’s
fundus
for
3. VS that are consistently WNL
 Resp: 18-20
location and tone every 15
4. C/S incision dsg. CDI
 BP: 110-113/58-67
minutes for the first hour
5. Maintains LOC and mental
Diastolic BP of 58 is slightly
following delivery, every 30
status that is considered
below ideal limits, but this
minutes for the second hour,
normal for this patient.
could be attributed to limited
and per hospital protocol (Q8H
6. Strong peripheral pulses
physical activity (pt. spent
at Woman’s Hospital M/B)
7. Capillary refill less than 3
much of day in bed).
thereafter. The fundus of the
seconds
4. C/S incision pressure dsg.
uterus may be located by
8. Skin and MM warm and pink.
remained CDI at all times. Not
starting at or slightly below the
9. No significant decrease in Hgb
removed per MD orders.
umbilicus and then slowly
or Hct since post-delivery
5. Pt. slept intermittently
ascending until it is felt. The
results.
throughout the day. However,
hand opposite the one used for
10. Voiding without difficulties and
she was easily aroused and,
palpation should be placed
absence of bladder distention.
when awake, remained alert
gently on the pubic symphysis.
11. Absence of straining and gasand oriented to person, place,
Rationale: The immediate
trapping r/t constipation
time and situation.
recovery period following birth 6. Radial and pedal pulses strong
Synthroid, Cytomel, Motrin,
Surfak, Benadryl
Objective Data:
 Vital Signs:
o 0800: T 98.7, P 86, RR
20, BP 113/58
o 1600: T 98.3, P 75, RR
18, BP 110/67
 IV: 18 G to R hand, patent, SL
o d/c’d 11/7/13 @ 08:30
 Neuro: Pt. AAOx4,
communicates and expresses
self appropriately, dressed
appropriately.
 CV: S1 & S2 present, regular
rhythm. Radial pulses strong,
even bil. Skin and MM warm,
pink. Capillary refill less than 3
seconds
 Resp: Respirations even and
unlabored. All lobes CTA. No
S&S of resp. distress.
 GI: Bowel sounds present x4
quadrants. No BM since
11/5/13. Passes flatus.
 GU: Voided x3. Voids per
bathroom s difficulties. Fundus
is firm, midline, and 1
fingerbreadth below umbilicus.
 Lochia: Scant amount of lochia
rubra present. No signs of
frank hemorrhage.
 Incision: Lower transverse
uterine incision (C/S) c Insorb
staples. Pressure dsg. CDI.
is the time at which the
mother’s risk of postpartal
hemorrhage is the highest. A
firm, contracted uterus
compresses the maternal blood
vessels and reduces the risk of
hemorrhage. Placing the nonpalpating hand on the pubic
symphysis while palpating helps
to support the uterus and
prevent uterine prolapse.
and equal bilaterally.
7. Capillary refill to all
extremities less than 3
seconds.
8. Skin warm, dry, and
appropriate for the pt.’s
ethnicity. MM pink and moist.
9. Hgb/Hct values decreased
slightly from 12.5/36 (predelivery) to 10.7/31.5
(immediate post-delivery).
However, this decrease can be
4. At each fundal check where a
attributed to blood loss
boggy fundus is noted, gently
(estimated 800 mL) during
massage the fundus. As with
labor and C/S. Most recent
palpation, the non-dominant
results are 11.4/34.3. No
hand should remain at the
significant decreases noted
pubic symphysis while the
between immediate postdominant hand gently
delivery results and most
massages the fundus in a
recent results.
circular motion. Rationale:
10. Voids independently per
Gentle massage of the fundus
bathroom without difficulties.
assists with postpartal uterine
Bladder soft and noncontractility and reduces the
distended upon each
risk of hemorrhage.
assessment.
11. Passes flatus. No evidence of
5. Teach the pt. how to palpate
gas trapping. No BM since
her own fundus, how to
11/5/13. No straining to pass
identify when a fundal massage
stool.
is needed, and how to properly Was overall goal met? Yes No
massage the fundus. Encourage
the patient to perform selfPlan should be…
massages as often as desired
Continued?
between routine fundal checks
Modified?
and instruct them to alert the
Terminated?
nurses’ station using the call
light if the fundus feels boggy
and does not contract in
response to massages.
Rationale: Teaching the patient
how to properly palpate and
massage her own fundus gives
her a sense of control over her
care, which may decrease
anxiety. Furthermore, it allows
for more frequent selfassessment and intervention,
which promotes a more
desirable outcome (in this case,
a firm, contracted uterus).
6. Monitor lochia and assess
color, amount, consistency, and
odor with each fundal check or
as needed for soiled peri-pads
or linens. For large amounts of
bleeding (in which case the pad
is saturated), weigh the soiled
pad to determine amount.
Notify HCP if lochia has foul
odor or persists in heavy
amounts. Rationale: Lochia is
normal vaginal discharge
following birth. A small to
moderate amount of lochia
rubra (red) is to be expected,
Persistent, heavy lochia may
indicate postpartal hemorrhage
and should be reported to the
HCP. Foul-smelling lochia may
indicate an infection and should
also be reported.
7. With each fundal assessment,
assess VS, LOC, cardiovascular
function (i.e. heart sounds,
peripheral pulses, capillary
refill, skin color), and
respiratory status (i.e.
respiratory patterns and effort,
breath sounds, S&S of distress).
Report any assessment
findings indicative of
hemorrhage or hypovolemia to
HCP. Also inspect the C/S
incision pressure dsg, which
should remain occlusive, clean,
dry, and intact. In the event the
dsg. is soiled or no longer
intact, report these findings to
the HCP and re-dress incision
per MD orders. Rationale:
Excessive blood loss r/t
postpartal hemorrhage may
manifest in S&S of hypovolemia
(i.e.  BP,  HR, arrythmias,
weak or absent pulses, delayed
capillary refill). Consequently,
body tissues may not be
adequately perfused and tissue
hypoxia (i.e. altered mental
status or LOC, cyanosis,  RR,
S&S of respiratory distress) may
result.
8. Monitor I&O during the
immediate recovery period and
palpate bladder for fullness or
distention. If either urinary
elimination or mobility is
impaired (i.e. due to effects of
epidural), provide intermittent
catheterization every 2 hours
or as needed for bladder
distention. Rationale: A full or
distended bladder may place
excessive pressure on the uterus
and inhibit involution.
Catheterization may be needed
if the pt. is unable to ambulate
or void independently.
9. Administer Surfak 100 mg po
BID and PRN S&S of
constipation or gas pains.
Assess bowel sounds and for
flatus, BM characteristics, and
bloating with routine
assessments Q8H. Rationale:
Straining r/t constipation and
trapping of gas in the GI tract
are both factors that place
increased pressure on the
fundus (inhibiting involution)
and C/S incision. Surfak, a stool
softener, draws water into the
bowel lumen, making stools
easier to pass.
10. Monitor CBC results,
particularly Hgb and Hct.
Compare results to predelivery baselines and monitor
trends in post-delivery results.
Rationale: Decreased Hgb and
Hct may be indicative of blood
loss. Some blood may be lost due
to the labor process, C/S, or
immediately following labor (i.e.
lochia). However, significant
decreases persisting after the
immediate recovery period may
indicate hemorrhage.
11. In the event of hemorrhage or
hypovolemia, administer
additional IVF, volume
expanders (i.e. albumin), or
blood products as ordered by
MD. Rationale: Large amounts
of blood loss may necessitate
administration of blood
products to maintain adequate
blood volume. Volume
expanders, such as albumin,
increase the intravascular COP,
which draws fluid into the
vascular space and increases
fluid volume.
Assessment
Subjective Data:
 Pt. is 35 y/o African American
female transferred to M/B unit
on 11/5/13.
 Transferred following lower
transverse C-section
performed in response to nonreassuring FHT and FTP 2º
CPD.
 OB Hx.:
o GP: 2/0
o GTPAL: 2/0/0/1/0
 Gestational age (at delivery):
38 weeks
o LMP: 2/12/13
o EDB: 11/19/13
 Hx. of Gestational DM & HTN,
physiologic anemia (during
pregnancy), and substance
abuse (cocaine & marijuana).
 No episiotomy performed on
mother while in labor. No
cervical lacerations.
 BP prior to delivery: 126/70
 Medications administered
during labor: Bupivacaine
(epidural), Duramorph IVP,
Pitocin IVPB
 Pitocin IVPB also administered
on L&D during immediate
recovery period following C/S
 Current medications:
Synthroid, Cytomel, Motrin,
Surfak, Benadryl
Objective Data:
Diagnosis/Plan
Dx: Acute pain
R/T: lower transverse uterine
incision
2º: Caesarean section
Goal: Pt. will demonstrate
effective pain management
throughout the remainder of the
second postpartal day.
AEB:
1. Pt.-stated pain level of 3/10 or
less on a 1-10 verbal pain scale
(Pt. indicated 3/10 to be
tolerable).
2. Absence of non-verbal signs of
pain (i.e. groans, grimacing,
tense posture, labored
breathing)
3. VS consistently WNL
4. Notifying nurse before pain
reaches intolerable level
5. Demonstration of effective
non-pharmacological pain
control measures.
6. Voiding without difficulties
and absence of bladder
distention.
7. Absence of gas pains and
straining with bowel
movements.
Interventions
Evaluation
1. Assess pain on an hourly basis
and prior to the administration
of analgesics. Have the pt. rate
her pain on a 0-10 scale and
assess pain location, quality,
duration, and frequency. Also
ask the pt. to determine a
maximum level of pain (using
the same scale) that she deems
to be tolerable. Instruct pt. to
report pain using her call light
before it reaches this maximum
level. Re-assess pain level
within 30 minutes of any
intervention. Rationale:
Assessing pain characteristics,
such as intensity, quality,
location, duration, and
frequency helps in determining
pain etiology and promotes
prompt intervention.
Determining a maximum
tolerable pain level establishes a
goal for pain management.
Notifying the nurse of pain
before it becomes intolerable
assists in maintaining pain at a
tolerable level. Re-assessing
pain following interventions
evaluates the effectiveness of
these interventions.
Outcomes:
1. Pt. reported pain goal of 3/10
to be tolerable. Throughout
most of the shift, pt. reported
mild constant soreness of 2/10
to her incision site. Also, she
reported intermittent
cramping pain (she compared
it to “muscle cramping after a
run”) to the left side of her
abdomen (5/10 at 08:30 and
2/10 at 15:00). On both
occasions, she reported pain
had subsided to “less than
1/10” and cramping had
ceased within 30 minutes
receiving Motrin.
2. Grimacing, groaning, and
tensing of extremities noted
with palpation of fundus and
physical exertion (i.e. getting
out of bed to ambulate). No
incidence of labored breathing
or change in LOC.
3. VS for this shift were as
follows:
o 08:00: T 98.7, P 86, RR
20, BP 113/58
o 1600: T 98.3, P 86, RR
20, BP 110/67
No significant increases in BP,
HR, or RR that can be
attributed to pain.
4. Pain was reported to be 5/10
at 08:30, which exceeded the
pain goal. Teaching about early
reporting of pain was
2. When assessing for pain,
observe closely for nonverbal
pain cues, such as facial
grimacing, anxiety, tense body
language, moaning or groaning,









Vital Signs:
o 0800: T 98.7, P 86, RR
20, BP 113/58
o 1600: T 98.3, P 75, RR
18, BP 110/67
IV: 18 G to R hand, patent, SL
o d/c’d 11/7/13 @ 08:30
Neuro: Pt. AAOx4,
communicates and expresses
self appropriately, dressed
appropriately.
Pain:
o Pt.-stated pain goal is
3/10
o Constant soreness to
C/S incision 2/10
o At 08:30, reported
cramping pain to left
side of abdomen (5/10).
o At 15:00, reported
cramping pain to left
side of abdomen (2/10).
o Mild facial grimacing,
groaning, and tensing of
extremities noted when
palpating fundus and
with physical exertion.
CV: S1 and S2 present, regular
rhythm.
Resp: Respirations even
unlabored. No S&S of distress.
GI: Bowel sounds present x4
quadrants. No BM since before
C/S. Passes flatus.
GU: Voids per bathroom s
difficulties. Bladder soft and
non-distended
Incision: Lower transverse
uterine incision (C/S) c Insorb
lethargy, and increased
respiratory effort. Rationale:
Pain often elicits nonverbal
responses, which may assist the
nurse in promptly identifying
the presence of pain.
reinforced and at 15:00, the pt.
requested Motrin prior to
ambulating when her pain was
2/10, within the identified
goal.
5. Pt. and family member
maintained a quiet resting
3. Assess VS every 8 hours, noting
environment, which the
any increases from the
patient stated was helpful. She
patient’s baseline blood
also said she would look over
pressure, heart rate, or
at her son when she was
respiratory rate. Rationale: The
hurting and said he “reminds
pain response is a response of
her it’s all worth it.” Splints
the sympathetic nervous system
incision properly with pillow
and may result in hypertension,
when coughing.
tachycardia, and tachypnea.
6. Voids independently per
bathroom without difficulties.
4. Before pain reaches an
Bladder soft and nonintolerable level, instruct pt. on
distended.
which pharmacological options 7. No S&S of gas pains (bloating,
are available for pain
generalized cramping,
management. Also explain and
hyperflatulence, excessive
assess understanding of nonbelching). No BM since
pharmacological pain measures
delivery but passes flatus.
(i.e. distraction, dim lights,
quiet environment, guided
imagery, music). Rationale:
Was overall goal met? Yes No
Non-pharmacological pain
Plan should be…
interventions are shown to be
Continued?
both safe and effective,
Modified?
particularly when combined
Terminated?
with pharmacologic
interventions. Pt. education is
best received and understood at
a time when pain and relate
anxiety are under control.
5. For pain exceeding the pt.’s
maximum tolerable level,
administer Motrin 600 mg Q6H
staples. Pressure dsg. CDI.
PRN. For severe pain (greater
than 7/10) administer Percocet
5/325 Q6H PRN. Do not
administer acetaminophen in
excess of 4000 mg per day.
Rationale: Motrin (ibuprofen) is
an NSAID that limits the
conversion of arachadonic acid
to prostaglandins, thus dulling
the sensation of inflammatory
pain. Percocet is a combination
of oxycodone, an opiate
analgesic that dulls the CNS
sensation of pain, and
acetaminophen, a non-narcotic
prostaglandin inhibitor that
reduces inflammatory pain
primarily in the CNS
(mechanism similar to that of
NSAIDS). When using
pharmacologic agents to
manage pain, it is best to begin
by using the most conservative
(in this case, Motrin) means
available to achieve analgesia.
Doses of acetaminophen
exceeding 4000 mg per day may
result in liver damage.
6. For pain unrelieved by
medications listed above,
contact MD for additional
orders. Rationale: Currently, the
only analgesics ordered for this
patient are Motrin and Percocet.
If these prove to be ineffective,
additional orders must be
obtained for other analgesics to
be administered. Also, this
patient has a history of
substance abuse, which may
affect pain threshold and
response to analgesics. More
aggressive drugs and/or doses
may be needed if analgesia is
not achieved.
7. Ask patient about urinary
output Q2H. If less than 30
mL/hr, assess bladder for
distention. Encourage frequent
voiding. If unable to void or
ambulate independently,
provide intermittent
catheterizations Q2H PRN.
Rationale: A full or distended
bladder may place increased
pressure on the patient’s uterus
and C/S incision, both of which
are sources of pain in the
postpartal period. If patient is
unable to void independently,
catheterizations may be
necessary to prevent bladder
distention.
8. Administer Surfak 100 mg po
BID and PRN for constipation
or gas pains. Rationale:
Trapping of gas and straining to
pass stools, both of which may
result from constipation,
increase intra-abdominal
pressure, which may in turn
increase pain in the postpartal
period. Surfak, a stool softener,
draws water into the bowel
lumen to soften the stool and
make it easier to pass.
9. Encourage turning, coughing,
and deep breathing Q2H.
Instruct pt. to splint her
incision with a pillow when
coughing. Rationale: Turning,
coughing, and deep breathing
help to promote lung expansion
in patients who have received
epidural anesthesia. These
behaviors also promote clearing
of secretions that may
accumulate in the airway from
prolonged inactivity. However,
coughing increases intraabdominal pressure and may
cause incisional pain. Splinting
may help to reduce sensation of
pain with coughing.
10. Encourage ambulation in the
hallway (down the hall and
back to the room) at least Q4H
and more frequently as
tolerated. Offer pain
medication 30 minutes prior to
ambulation. Rationale:
Frequent ambulation helps to
reduce muscle stiffness from
inactivity, promotes circulation
to facilitate postpartal healing,
reduces risk of respiratory
complications, and helps to
promote GI motility to alleviate
constipation and gas trapping.
Pre-medicating for pain prior to
ambulating may reduce the pain
the patient experiences with
physical exertion, making
ambulation amore desirable
activity.
11. Encourage pt. to refrain from
gas-forming foods (i.e. milk and
carbonated drinks) and avoid
the use of straws when
drinking. Rationale: Gas
forming foods and the use of
straws (which promote air
intake) increase the amount gas
in the pt.’s GI tract, which may
increase intra-abdominal
pressure and result in gas pains.