POST PARTUM Maiden Name: Age: Husband: Place of Delivery: Home Time and Date of Delivery: August 17,

2011 Midwife: Type of Delivery: NSD Gender of the Baby: Female

Post natal Assessment Vital Signs: BP: 110/70 mmhg RR:22bpm PR: 78 bpm Temp: 36.4 C Breast: engorged and facilitates breastfeeding Uterus: firm and contracted Bladder: voids freely to a yellowish colored urine moderate in amount Bowel: positive bowel movement Lochia: with whitish vaginal discharge, scanty in amount Episiotomy: none Homans sign: no pain felt upon dorsiflexion Emotional Status: with stable emotional status Bonding with infant: seen cuddling and breast feeding her baby

Health Teachings: -proper care of perineum, washing from front to back to avoid infection -Instructed to eat Iron rich foods such as green leafy vegetables and Vit. C rich foods such as dalandan -Importance of breastfeeding -Proper way of breastfeeding -Proper breast care -Importance of complete immunization of the child -Instructed to visit the health center for check-up after six weeks

Focus -Risk for Infection

Data -with traumatized tissue -with slightly pale conjunctiva -with slightly pale ,lips with pale nail beds ;

Action - Evaluated clients hygiene. Stressed need for hand washing before and after perineal pad changes and before

Response -Verbalized proper care of perineum -Verbalized the importance of diet rich in protein, carbohydrates, iron zinc and Vit. A , B-complex and C

capillary refill time of 1- handling breast infant. 2 seconds -Noted the amount and color of lochia flow -Assessed nipple for cracks and fissures. Provide or reinforced information regarding breast and nipple care -Discussed dietary practices. Stressed need for increased amount of food rich in protein, carbohydrates, iron zinc and Vit. A , B-complex and C

Infant Assessment

Vital Signs: T: 35.6 C CR: 122 bpmRR: 29 bpm

Head Circumference: Chest Circumference: WT.: -with good sucking reflex - with positive rooting, babinski, Moro and hand grasping reflex -Vitamin K given

Focus -Risk for altered body temperature r/t immaturity of hypothalamus .

Data -Body temp=35.6 C

Action -Assessed newborns temperature. -Assisted parents in recognizing importance of heat regulation ; helps protects newborn from harm by temperature extremes -Assessed environmental temperature and neonates dress and coverings in relation parental attire -Suggested of using appropriate hat in all temperature.

Response -Temp=36C -Mothers verbalized the importance of maintaining the temperature of the baby -Seen wearing hat

MARIA DEANNA S. CANTOS BSN IV/ GROUP 5/SLSU