CLIENT ASSESSMENT DATA BASE
Activity/Rest
Lack of energy, fatigue, inability to maintain usual/expected routines
Circulation
Vital signs have returned to normal prepregnancy levels.
Ego Integrity
Emotional response may include irritability, anxiety, or feeling emotionally overwhelmed.
Elimination
Bowel sounds are active in all quadrants; usual elimination pattern resumes.
Abdominal muscle tone improving; flaccidity may persist.
Dipstick urinalysis for albumin, ketones, and glucose negative.
Food/Fluid
Return to prepregnancy weight, with retention of approximately 60% of weight gain in excess of 24 lb
Safety
Perineal episiotomy/laceration repair, cesarean incision should be healed.
Striae and linea nigra beginning to fade.
Sexuality
Lochial flow is absent.
Menstruation may resume beginning 4–5 wk postpartum, especially in nonlactating client.
Libido may be decreased.
Intercourse may be painful initially (dyspareunia).
Breasts in nonlactating client are soft, nontender, and of pregravid size; breasts in lactating client are full, free of nipple cracks and fissures, and lactation is well established.
Uterus not palpable, having returned to near pregravid size.
Pelvic examination, if performed, shows restored muscle tone, with cervix healed and closed, appearing as transverse slit.
Social Interaction
Comfort with parenting role; infant integrating into family unit
May be planning on returning to/seeking employment, or involvement in activities outside the home
DIAGNOSTIC STUDIES
Dependent on assessment findings, and individual client needs.
Hb/Hct: return to normal levels±5%, e.g., 12 g and 37%
Papanicolaou Smear: negative
NURSING PRIORITIES
1. Promote maternal/infant well-being.
2. Provide/reinforce health teaching.
3. Foster positive client and family adaptation to newborn.
DISCHARGE GOALS
1. Maternal/infant physiological/psychological needs being met.
2. Current health care behaviors and ongoing needs understood.
3. Satisfactory adaptation to parenting roles reported/observed.
Activity/Rest
Lack of energy, fatigue, inability to maintain usual/expected routines
Circulation
Vital signs have returned to normal prepregnancy levels.
Ego Integrity
Emotional response may include irritability, anxiety, or feeling emotionally overwhelmed.
Elimination
Bowel sounds are active in all quadrants; usual elimination pattern resumes.
Abdominal muscle tone improving; flaccidity may persist.
Dipstick urinalysis for albumin, ketones, and glucose negative.
Food/Fluid
Return to prepregnancy weight, with retention of approximately 60% of weight gain in excess of 24 lb
Safety
Perineal episiotomy/laceration repair, cesarean incision should be healed.
Striae and linea nigra beginning to fade.
Sexuality
Lochial flow is absent.
Menstruation may resume beginning 4–5 wk postpartum, especially in nonlactating client.
Libido may be decreased.
Intercourse may be painful initially (dyspareunia).
Breasts in nonlactating client are soft, nontender, and of pregravid size; breasts in lactating client are full, free of nipple cracks and fissures, and lactation is well established.
Uterus not palpable, having returned to near pregravid size.
Pelvic examination, if performed, shows restored muscle tone, with cervix healed and closed, appearing as transverse slit.
Social Interaction
Comfort with parenting role; infant integrating into family unit
May be planning on returning to/seeking employment, or involvement in activities outside the home
DIAGNOSTIC STUDIES
Dependent on assessment findings, and individual client needs.
Hb/Hct: return to normal levels±5%, e.g., 12 g and 37%
Papanicolaou Smear: negative
NURSING PRIORITIES
1. Promote maternal/infant well-being.
2. Provide/reinforce health teaching.
3. Foster positive client and family adaptation to newborn.
DISCHARGE GOALS
1. Maternal/infant physiological/psychological needs being met.
2. Current health care behaviors and ongoing needs understood.
3. Satisfactory adaptation to parenting roles reported/observed.
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