STAGE IV (FIRST 4 HOURS FOLLOWING DELIVERY OF THE PLACENTA)
CLIENT ASSESSMENT DATA BASE
Activity/Rest
May appear “energized” or fatigued/exhausted, sleepy
Circulation
Pulse usually slow (50–70 beats per minute [bpm], owing to vagal hypersensitivity).
Blood pressure (BP) variable; may be lower in response to analgesia/anesthesia, or elevated in response to oxytocin administration or pregnancy-induced hypertension (PIH).
Edema, if present, may be dependent (e.g., confined to lower extremities); or may include upper extremities and facies, or may be generalized (signs of PIH).
Blood loss during labor and delivery up to 400–500 ml for vaginal delivery or 600–800 ml for cesarean birth.
Ego Integrity
Emotional reactions regarding birth experience varied and changeable, e.g., excitation, disinterest (exhausted), or disappointment
May express concern or apologize for intrapartal behavior or loss of control; may express fears regarding condition of newborn and immediate neonatal care
Elimination
Hemorrhoids often present and protruding.
Bladder may be palpable over symphysis pubis, or urinary catheter may be in place.
Diuresis may occur if pressure of presenting part obstructs urinary flow, and/or intravenous (IV) fluids are administered during labor and delivery.
Flood/Fluid
May report thirst, hunger, or nausea
Neurosensory
Sensation and movement of lower extremities decreased in presence of spinal anesthesia or caudal/epidural analgesia.
Hyperreflexia may be present (suggests developing or persistent hypertension, especially in diabetic, adolescent, or primiparous client).
Pain/Discomfort
May report discomfort from various sources; e.g., afterpains, tissue trauma/episiotomy repair, bladder fullness, or feeling cold/muscle tremors with “chills”
Safety
Slight temperature elevation initially (exertion, dehydration).
Episiotomy/laceration repair intact, with tissue edges closely approximated.
Perineum free of redness, edema, ecchymosis, or discharge.
Striae may be present on abdomen, thighs, and breasts.
Sexuality
Fundus firmly contracted, midline, and located at the level of the umbilicus
Moderate amount of vaginal drainage or lochia, dark red, with only a few small clots at most (up to small plum size)
Breasts soft, with nipples erect
Social Interaction
Varied response to infant based on individual expectations, energy level, response of others, and condition of infant
Teaching/Learning
Various medications may have been administered during intrapartal period (note time and amount).
Questions or concerns voiced regarding self/infant care.
DIAGNOSTIC STUDIES
Hemoglobin/Hematocrit (Hb/Hct), Complete Blood Count (CBC), Urinalysis (UA), Other Studies: May be done as indicated by physical findings.
NURSING PRIORITIES
1. Promote family unity and bonding.
2. Prevent or control bleeding.
3. Enhance comfort.
DISCHARGE CRITERIA (FROM RECOVERY SETTING)
1. Physiologically stable
2. Ambulating/appropriate movement of lower extremities
Full Nursing Care Plan Stage 4
CLIENT ASSESSMENT DATA BASE
Activity/Rest
May appear “energized” or fatigued/exhausted, sleepy
Circulation
Pulse usually slow (50–70 beats per minute [bpm], owing to vagal hypersensitivity).
Blood pressure (BP) variable; may be lower in response to analgesia/anesthesia, or elevated in response to oxytocin administration or pregnancy-induced hypertension (PIH).
Edema, if present, may be dependent (e.g., confined to lower extremities); or may include upper extremities and facies, or may be generalized (signs of PIH).
Blood loss during labor and delivery up to 400–500 ml for vaginal delivery or 600–800 ml for cesarean birth.
Ego Integrity
Emotional reactions regarding birth experience varied and changeable, e.g., excitation, disinterest (exhausted), or disappointment
May express concern or apologize for intrapartal behavior or loss of control; may express fears regarding condition of newborn and immediate neonatal care
Elimination
Hemorrhoids often present and protruding.
Bladder may be palpable over symphysis pubis, or urinary catheter may be in place.
Diuresis may occur if pressure of presenting part obstructs urinary flow, and/or intravenous (IV) fluids are administered during labor and delivery.
Flood/Fluid
May report thirst, hunger, or nausea
Neurosensory
Sensation and movement of lower extremities decreased in presence of spinal anesthesia or caudal/epidural analgesia.
Hyperreflexia may be present (suggests developing or persistent hypertension, especially in diabetic, adolescent, or primiparous client).
Pain/Discomfort
May report discomfort from various sources; e.g., afterpains, tissue trauma/episiotomy repair, bladder fullness, or feeling cold/muscle tremors with “chills”
Safety
Slight temperature elevation initially (exertion, dehydration).
Episiotomy/laceration repair intact, with tissue edges closely approximated.
Perineum free of redness, edema, ecchymosis, or discharge.
Striae may be present on abdomen, thighs, and breasts.
Sexuality
Fundus firmly contracted, midline, and located at the level of the umbilicus
Moderate amount of vaginal drainage or lochia, dark red, with only a few small clots at most (up to small plum size)
Breasts soft, with nipples erect
Social Interaction
Varied response to infant based on individual expectations, energy level, response of others, and condition of infant
Teaching/Learning
Various medications may have been administered during intrapartal period (note time and amount).
Questions or concerns voiced regarding self/infant care.
DIAGNOSTIC STUDIES
Hemoglobin/Hematocrit (Hb/Hct), Complete Blood Count (CBC), Urinalysis (UA), Other Studies: May be done as indicated by physical findings.
NURSING PRIORITIES
1. Promote family unity and bonding.
2. Prevent or control bleeding.
3. Enhance comfort.
DISCHARGE CRITERIA (FROM RECOVERY SETTING)
1. Physiologically stable
2. Ambulating/appropriate movement of lower extremities
Full Nursing Care Plan Stage 4
Chinese
French
German
Italian
Japanese
Korean
Russian
Spanish
