NCP The Client at 4 Hours to 2 Days Postpartum

CLIENT ASSESSMENT DATA BASE

Progressive continuation of data base for stage IV.

Activity/Rest

Extreme fatigue and decreased energy level may be noted.
Insomnia may be noted.

Circulation

Diaphoretic episodes occur more often during night.

Ego Integrity

Irritability, tearful/crying (“postpartum blues” often noted about day 3 following delivery)

Elimination

Diuresis between day 2 and 5.
Constipation may occur.

Food/Fluid

Loss of appetite may be reported at about day 3.

Pain/Discomfort

Perineal soreness from stretching, and sutures if episiotomy performed/laceration occurred
Uterine contractions strong and regular in first 24-hr period, diminishing daily in frequency and intensity

Safety

Headache may be reported (subarachnoid/spinal block).

Sexuality

Uterus between one finger breadth above to two finger breadths below umbilicus at 12 hr following delivery, descending approximately one finger breadth daily thereafter
Lochia rubra continues for 2–3 days, progressing to lochia serosa with flow dependent on position (e.g., recumbent versus up and ambulating) and activity (e.g., breastfeeding or exercise).
Breasts: Production of colostrum first 48 hr progressing to mature milk, usually by day 3; may be earlier, depending on when breastfeeding is begun and how frequently mother nurses infant

NURSING PRIORITIES

1. Promote comfort and general well-being.
2. Prevent complications.
3. Support family bonding.
4. Provide information and anticipatory guidance.

DISCHARGE GOALS

1. Physiological/psychological needs being met
2. Complications prevented/resolving
3. Family bonding initiated
4. Postpartal needs understood