Postpartum Vaginal Delivery
UNFOLDING Reasoning
Anne Jones, 17 years old
Primary Concept
Reproduction
Interrelated Concepts (In order of emphasis)
• Clotting
• Clinical Judgment
• Communication
NCLEX Client Need
...
Postpartum Vaginal Delivery
UNFOLDING Reasoning
Anne Jones, 17 years old
Primary Concept
Reproduction
Interrelated Concepts (In order of emphasis)
• Clotting
• Clinical Judgment
• Communication
NCLEX Client Need Categories Percentage of Items from Each
Category/Subcategory
Covered in
Case Study
Safe and Effective Care Environment
• Management of Care 17-23% ✓
• Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12% ✓
Physiological Integrity
• Basic Care and Comfort 6-12% ✓
• Pharmacological and Parenteral Therapies 12-18% ✓
• Reduction of Risk Potential 9-15% ✓
• Physiological Adaptation 11-17% ✓
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
History of Present Problem
7:00 am First Day Post-Delivery Night Shift Report:
Anne Jones is a 17-year-old G1 P1 39 weeks’ gestation who delivered a healthy male infant at 2032 yesterday. Placenta
delivered at 2045. No pain medication was given. She received a 250 mL bolus of Pitocin 30 units/500 mL IV after the
delivery of the placenta then received 200 mL/hour until the IV bag was completed.
The uterus is firm, one finger breadth below umbilicus and midline — Lochia moderate rubra. Mid-line episiotomy
is well approximated, slightly bruised and perineum is slightly swollen. She had an ice pack applied to perineum
throughout the night. Anne is up and ambulating ad lib and voiding without difficulty. She had 500 mL in/850 mL urine
out. Vital signs: BP: 124/78, P: 74, R: 18, T: 98.6 F/37.0 C, O2: 98% room air, Pain 3/10 in perineum. She is on a regular
diet. She was positive for Group Beta strep (GBS) and received a total of three doses of ampicillin IVPB during labor,
her blood type is B-, and rubella positive.
Infant Report:
Infant Apgars were 8 and 9. Weight: 7 lbs. 0 oz. (3.2 kg), 20 inches (50.8 cm) long. Baby has breast fed and latched on
for five minutes on both sides three times, and Anne is holding and talking to her baby. She plans on having the baby
circumcised. The baby had three wet and meconium diapers. Cord blood was sent.
Personal/Social History:
Anne has her mother with her and seems to be relaxed but nervous. The father of the baby is not involved. She plans on
breastfeeding for “awhile.” Anne still lives at home, and her mother is planning on helping with the new baby and
appears supportive.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Report: Clinical Significance:
RELEVANT Data from Social History: Clinical Significance:
Patient Care Begins: You complete your first assessment:
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breastfeeding
P: 76 (regular) Quality: Cramping and tenderness of perineum
R: 18 (regular) Region/Radiation: Uterus and perineum
BP: 125/80 Severity: 4/10
O2 sat: 98% room air Timing: When breastfeeding and continuous for perineum
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Assessment Data: Clinical Significance:
Clinical Reasoning Begins…
1. Interpreting relevant clinical data, what is the primary concern? What primary health-related concepts does this
primary problem represent? (Management of Care/Physiologic Adaptation)
Problem: Pathophysiology of Problem in OWN Words: Primary Concept:
Current Assessment: Mom
GENERAL
APPEARANCE:
Calm and quiet appears tired. Baby in a crib next to the bed.
RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, heart sounds regular with no abnormal beats, pulses strong, equal with
palpation at radial/pedal/post-tibial landmarks, brisk cap refill, 1+ edema in lower
extremities bilaterally
NEURO: Alert and oriented to person, place, time, and situation (x4)
BUBBLE
3
BREAST: Lactating; soft, non-tender with evidence of colostrum
UTERUS: Fundus boggy 1 cm above umbilicus and deviated to the right
BLADDER: Voiding without difficulty. Denies any burning with urination. Hasn’t voided yet this
morning.
BOWELS: Abdomen soft/non-distended, bowel sounds audible per auscultation in all four quadrants,
positive flatus, no BM since delivery.
LOCHIA: States hasn’t changed pad this morning, peri-pad saturated with rubra lochia, small clots
noted.
EPISIOTOMY: Perineum slightly bruised and swollen, small hemorrhoids noted.
EXTREMITIES: Calves cool to touch, no tenderness bilaterally
EMOTIONAL: Quiet appears fatigued, currently interacting with baby
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reser
[Show More]
