VII. PHYSICAL ASSEMENT – General Appearance (DO NOT put “good” or WNL).

Caucasian women, short and well developed in clean crisp and neat scrubs with clean and neatly

styled hair. Her posture was relaxed and slouched. Skin was warm, pink, and soft to the touch.

Speech was clear and evenly paced. The woman was calm, cooperative and attentive. She also

responded appropriately and understood the questions asked.

Nursing Diagnosis Necessary Assessments/ Interventions RationaleImbalance nutrition less than body requirements R/T: pregnancy AEB: loss of weight with adequate food intake, nausea and vomiting

1. Educate on proper weight gain and calorie intake during pregnancy (Miller, 2011).

2. Discuss how to eat a balanced diet paying close attention to the amount of vitamins and minerals ingested (Miller, 2011).

3. Teach patient to avoid dangerous foods and substances (Miller, 2011).

4. Educate patient that it’s ok to indulge in cravings and avoid foods that cause nausea as long as it does not exclude entire food groups (Miller, 2011).

1. Inadequate and excessive weight gain during pregnancy has been associated with several adverse outcomes from both mom and baby (Miller, 2011).2. What a mother eats is baby’s main source of nutrients, although supplements are a good way to ensure adequate vitamin and mineral intake, women still need to be eating foods high in these things (Miller, 2011).3. Pregnant women are more susceptible to food borne illness due to physiological changes that occur during pregnancy. Also some substances while pregnant are harmful to the baby (Miller, 2011).4. Craving and nausea are due to abrupt changes in hormone levels and increase sense of taste and smell (Miller, 2011).

Risk for bleeding R/T history of excessive bleeding, extensive labor and postpartum thrombus formation.

1. Identify risk factors for postpartum hemorrhage with prenatal record or during birth (Burke, 2010).

2. Administer uterotonic drugs immediately after delivery of anterior shoulder (preferred drug is oxytocin) (WHO, 2006).

3. Immediately massage uterus through the abdomen until uterus is contracted (WHO, 2012).

4. Educate patient on importance of regularly emptying the bladder to maintain uterine tone (Burke, 2010).

1. Identifing risk factors is the first step to preventing postpartum hemorrhage (Ricci, 2009).2. Uterotonic drugs increase contraction effectiveness in uterus. Oxytocin is preferred because it’s effective in 2-3 minutes and has minimal side effects and can be used in all women (WHO, 2006).3. This is typically done to stimulate the uterus and promote uterine contractions (WHO, 2006).4. A distended bladder displaces the uterus from midline which impedes its ability to contract to reduce bleeding (Ricci, 2009).

References

Burke, C. (2010). Active expectant management of the third stage of labor and implementation

of a protocol. Journal Of Perinatal &Neonatal Nursing, 24(3), 215-228. Doi:

10.1097/JPN.0b013e3181e8ce90.

Miller, R.S. (2011). Nutritional needs during pregnancy. Nursing Made Easy, 9(5), 21-24. Doi:

10.1097/01.NME.0000403193.68168.d0

Ricci, S.S. (2009). Essentials of Maternity, Newborn, and Women’s health Nursing. (3rd e.d.).

Philadelphia, PA: Lippincott Williams &Wilkins.

World Health Organization- Department of making pregnancy safer. (2006). Retrieved October,

21, 2013 from http://wwww.who.int/maternal_child_adolescent/documents/postpartum/

en

World Health Organization- Department of Reproductive health. (2012). Retrieved October 21,

2013 from

http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/

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