CLIENT ASSESSMENT DATA BASE
Circulation
Vital signs within normal limits
Ego Integrity
Emotional tone and responses may vary from one of delight to a sense of overwhelming disorganization or anxiety, especially in first-time mother. Irritability, crying, “postpartum blues.”
Elimination
May report voiding difficulty or stress incontinence
May report difficulty with bowel evacuation, with decreased frequency, hard-formed stool
Pain/Discomfort
May report continued discomfort associated with afterpains.
Engorgement may be present in lactating client.
Safety
Episiotomy or cesarean incision free of edema, indurated areas, redness, and exudate; tissue edges approximated
Sexuality
Uterus nontender, palpable at symphysis pubis.
Lochial flow scant and pinkish-brown in color (serosa) and of 4–10 days’ duration.
Breasts in lactating client increased in size with increased milk supply.
Nipples free of redness, cracks, and fissures.
Engorgement may be present in lactating client, subsiding in nonlactating client.
DIAGNOSTIC STUDIES
Urine: Negative for albumin/glucose.
Additional testing as indicated; e.g., UA, culture and sensitivity, Hb/Hct or CBC to include WBC count.
NURSING PRIORITIES
1. Promote maternal/infant well-being.
2. Foster optimal adaptation to physical emotional changes.
3. Provide anticipatory guidance for optimal integration of new family member and adaptation to role changes
Circulation
Vital signs within normal limits
Ego Integrity
Emotional tone and responses may vary from one of delight to a sense of overwhelming disorganization or anxiety, especially in first-time mother. Irritability, crying, “postpartum blues.”
Elimination
May report voiding difficulty or stress incontinence
May report difficulty with bowel evacuation, with decreased frequency, hard-formed stool
Pain/Discomfort
May report continued discomfort associated with afterpains.
Engorgement may be present in lactating client.
Safety
Episiotomy or cesarean incision free of edema, indurated areas, redness, and exudate; tissue edges approximated
Sexuality
Uterus nontender, palpable at symphysis pubis.
Lochial flow scant and pinkish-brown in color (serosa) and of 4–10 days’ duration.
Breasts in lactating client increased in size with increased milk supply.
Nipples free of redness, cracks, and fissures.
Engorgement may be present in lactating client, subsiding in nonlactating client.
DIAGNOSTIC STUDIES
Urine: Negative for albumin/glucose.
Additional testing as indicated; e.g., UA, culture and sensitivity, Hb/Hct or CBC to include WBC count.
NURSING PRIORITIES
1. Promote maternal/infant well-being.
2. Foster optimal adaptation to physical emotional changes.
3. Provide anticipatory guidance for optimal integration of new family member and adaptation to role changes
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