BP – 127/80

SPO2 – 97

T – 36.9

HR – 82 Regular

R – 16

Soft Abdomen

Breath Sounds Clear

U/2 fundus

Bowel sounds active X4 but Hypoactive

Lochia Rubra

a little soreness and an hemorrhoid on 2nd degree tear that was repaired

RH +

GBS –

MMR – immune

Medications

–        Pain

o   Ibuprofen

o   Morphine

–        Postpartum hemorrhage

o   Oxytocin

o   Carboprost (Hemabate)

o   Misoprostol

–        Nausea/vomiting

o   Dimenhydrinate

–        Hemorrhoids

o   Hydrocortisone-zinc

 History

IBS (irritable bowel syndrome)

G – 2 T -1 P – 0 A – 1 L – 1

Baby

Resp – 44

Temp – 36.7

HR – 144

Bilimeter – 50

Birth weight – 3800 g

Day 1

–        Voided X 2

–        Bowel movement X2

Risk for impaired skin integrity related to soreness and hemorrhoid.

Goal #1 – Short-term: Mother will report being able to have a bowel movement with no problems by a week

Goal #2 – Long-Term: Patient will show no signs or worsening signs of soreness, hemorrhoids or irritation by 3 months.

Nursing Interventions

–        Administer stool softeners or laxatives that have been prescribed

–        Encourage diet in high fiber

–        Increase fluid intake

–        Use prescribed medicated creams or ointments.

–        Assess skin area regularly

–        Educate patient on avoidance of excessive wiping or rubbing of affected area

Rationale

–        Can assist in instantiating the first bowel movement for short term use only

–        Helps maintain bowel health and softens stool

–        helps to soften your stool

–        will help treat affected area

–        will help detect any worsening or improving sign and symptoms.

–        Help patient prevent worsening sign and symptoms.

Short Term – Not met, unable to evaluate.

Long term –I will not be able to evaluate success of this goal as there will be no way for me to evaluate in 3 months.