POST-PARTUM ASSESSMENT

Profile:

Patient’s Name: __K.L____________________________ Date & Time of Birth: 04/11/2018 4:45 A.M
AOG: __38 weeks_____________________ Type of Delivery: Normal Spontaneous Vaginal Delivery

ASSESSMENT AREA FINDINGS

B (Breast)  The patient was utilizing breastfeeding.

 Breast was inverted upon inspection.
 Absence of rashes, lumps and lesion of the
skin surface noted.
 Engorgement tenderness upon palpation.

 Absence incision, redness and lesion of the

skin surface noted upon inspection.
U (Uterus)  Firm uterus upon palpation.
 Height and position of the fundus descend
about 1 cm below the umbilicus.


 Presence of scars, straie on the abdomen

noted upon inspection.
 Presence of active bowel sounds upon
B (Bowels) auscultation.
 Presence of dullness upon percussion.
 Absence of pain upon palpation.
  Absence of catheter upon inspection.
 Patient complained presence of pain upon
urination.
B (Bladder)
 Urination frequency about 4 times a day every
after 3 hours.
 Firmness and discomfort upon palpation.

 Absence of REEDA (redness, edema,
ecchymosis, discharges, approximation of the
skin edges upon inspection.
L (Lochia)  Presence of lochia rubra with small blood clots
noted.
 Patient used 2-3 peripads per day.

 Absence of REEDA in perineum area upon

E (Episiotomy/Laceration/C Section Incision) inspection.
 Second- degree laceration noted.
 Patient complained presence of pain upon
ambulation due to laceration.

S (Skin)  Absence of skin rashes, lesions and irritation

in the upper and lower extremities except in
the perineum area.
 Absence of edema on the both upper and
lower extremities specifically on face and legs.
 Patient complained presence of pain upon
ambulation due to laceration.
  Absence of pain upon dorsiflexion of the foot
noted upon inspection.
 Absence of edema and varicose veins on the
H (Homan’s Sign) both legs.
 Negative for human sign.

 Patient has taking –in maternal adjustment

phase.
 Patient gained emotional support from her
E (Emotional Support) husband and her family.
 Presence of anxiety for her baby tested
positive in meconium staining.
 DRUG INDICATIONS MECHANISM OF ACTION ADVERSE EFFECTS NURSING RESPONSIBILITIES
Generic Name: -To prevent and treat Increases motor activity of the CNS: seizures, stroke with I.V.• Monitor and record blood
uterus by direct stimulation of use, dizziness, headache,
Methylergonovine maleate postpartum hemorrhage pressure, pulse rate, and
hallucinations.
the smooth muscle, uterine response; report
Brand Name: caused by uterine atony CV: hypertension, transient
shortening the third stage of chest pain, palpitations, sudden change in vital signs,
Methergine or subinvolution. labor, and reducing blood loss. hypotension, thrombophlebitis.
frequent periods of uterine
Dosage: EENT: tinnitus, nasal congestion.
GI: nausea, vomiting, diarrhea,relaxation, and character and
250 mg
-For excessive uterine Methergin
foul taste. amount of vaginal bleeding.
bleeding or other ↓
Stimulates uterine CONTRAINDICATION • Monitor contractions, which
emergencies.
Route: smooth S may begin immediately.
PO muscles Contractions may continue for
↓ • Contraindicated in up to 45 minutes after I.V. use
Onset: CLASSIFICATION
producing sustained pregnant patients, in patients or for 3 hours or more after
5-10 mins. sensitive to ergot
contractions P.O. or I.M. use.
preparations, and in patients
Peak: ↓ • Look alike–sound alike: Don’t
with hypertension or
30 mins. thereby shortens the confuse
toxemia.
third stage of labor Methergine with terbutaline.
Frequency: • Use cautiously in patients
Ergot alkaloid with sepsis, obliterative
TID
vascular disease, or hepatic
or renal disease.
• Use cautiously during last
stage of labor.
 Generic Antihemorrhagic and Forms a reversible GI disorders: nausea, - Unusual change in bleeding
Name: pattern should be immediately
antifibrinolytic for complex that displaces vomiting. CNS:
Tranexamic Acid reported to the physician.
effective hemostasis in plasminogen from fibrin anorexia, headache
- For women who are taking
Brand Name: various surgical and resulting in inhibition of may appear, impaired Tranexamic acid to control heavy
Lysteda, Hemostan clinical cases, in fibrinolysis, it also inhibits renal insufficiency, bleeding, the medication should
Dosage: traumatic injuries, post- the proteolytic activity of hypotension when IV only be taken during the
tooth extraction and plasmin. injection is too rapid. menstrual period.
250mg
other dental procedures. CONTRAINDICATION -Tranexamic Acid should be used
S with extreme caution in CHILDREN
younger than 18 years old; safety
and effectiveness in these children
Route: Patients predisposed is not confirm.
PO to thrombosis.
CLASSIFICATION
Onset: Prophylaxis during
unkown pregnancy and before
Antihemophilic agent delivery.
Peak:
3 hours
Frequency:
BID
 DRUG INDICATIONS MECHANISM OF ACTION ADVERSE EFFECTS NURSING RESPONSIBILITIES
Generic Name: -Mild to moderate Inhibits cell-wall synthesis
Amoxicillin infections of the ear, during bacterial Oliguric renal failure. • If large doses are given or if
therapy is prolonged, bacterial or
Brand Name: nose, and throat; skin multiplication. CONTRAINDICATION fungal super infection may occur,
Amox, Apo-Amoxi, DisperMox, and skin structure; or GU S
especially in elderly, debilitated,
Moxatag, Novamoxin†, Nu- tract. or immunosuppressed patients.
Amoxi - Mild to severe infections • Contraindicated in • Clostridium difficile–associated
of the lower respiratory patients hypersensitive to diarrhea, ranging from mild
Dosage:
drug or other penicillins. diarrhea to fatal colitis, has been
250 mg tract and severe
• Use cautiously in reported with nearly all
Route: infections of the ear,
patients with other drug antibacterial agents, including
PO allergies (especially to amoxicillin. Evaluate patient if
CLASSIFICATION
Onset: cephalosporins) because diarrhea occurs.
nose, and throat; skin of possible cross- • Amoxicillin usually causes fewer
Unkown
and skin. sensitivity. cases of diarrhea than ampicillin.
Peak: • Use cautiously in those • Look alike–sound alike: Don’t
Antibiotic
1-2 hours with mononucleosis confuse amoxicillin with
Penicillin-class
because of high risk of amoxapine.
Frequency: Antibacterial
maculopapular rash.
BID
 DRUG INDICATIONS MECHANISM OF ACTION ADVERSE EFFECTS NURSING RESPONSIBILITIES
Generic Name: Pain -Anthracitic acid
Headache, nausea, vomiting, epigastric
Mefenamic Acid and derivative. Like -Assess patients who develop
pain, GI bleeding. Rarely, diarrhea,
disorientation, excitation, coma, severe diarrhea and vomiting for
Brand Name: Inflammation. ibuprofen inhibits
drowsiness, tinnitus, fainting, and dehydration and electrolyte
Ponstan, Ponste prostaglandin synthesis occasionally convulsions. Management: imbalance.
Dosage: and affects platelet Symptomatic and supportive treatment. -Lab tests: With long-term therapy
In acute over dosage, empty the
500 mg
function. (not recommended) obtain
stomach immediately by inducing
- No evidence that it is emesis or by gastric lavage followed by periodic complete blood counts,
Route:
superior to aspirin. admin of activated charcoal. Hct and Hgb, and kidney function
PO tests.
CONTRAINDICATION
Onset: S -Discontinue drug promptly if
diarrhea, dark stools,
2 hours CLASSIFICATION
Hypersensitivity to mefenamic acid,
hematemesis, ecchymosis,
Peak: epistaxis, or rash occur and do not
aspirin or other NSAIDs. Patient w/
4 hours inflammatory bowel disease, active use again. Contact physician.
ulceration or chronic inflammation of
Frequency:
the upper or lower GI tract, renal
OD Anti-inflammatory failure. History of asthma, urticaria,
allergic-type reactions. Treatment of
drug (NSAID).
perioperative pain in the setting of
CABG surgery.
 Anatomy and Physiology of Female Reproductive System

Internal Structures

Ovaries

 The ovaries are the ultimate life-maker for the females.

 For its physical structure, it has an estimated length of 4 cm and width of 2 cm and is 1.5 cm thick. It appears to be

shaped like an almond. It looks pitted, like a raisin, but is grayish white in color.

 It is located proximal to both sides of the uterus at the lower abdomen.

 For its function, the ovaries produce, mature, and discharge the egg cells or ova.

 Ovarian function is for the maturation and maintenance of the secondary sex .
 Fallopian Tubes

 The fallopian tubes serve as the pathway of the egg cells towards the uterus.

 Fertilization takes place ampulla of the fallopian tube.

 The muscle layer is responsible for the peristaltic movements that propel the ovum forward.

 The distal ends of the fallopian tubes are open, making a pathway for conception to occur.

Uterus

 The uterus is described as a hollow, muscular, pear-shaped organ.

 The uterus has an estimated length of 5 to 7 cm and width of 5 cm. it is 2.5 cm deep in its widest part.

 For non-pregnant women, it is approximately 60g in weight.

  Its function is to receive the ovum from the fallopian tube and provide a place for implantation and

nourishment.

 It also gives protection for the growing fetus.

 The body forms the bulk of the uterus, being the uppermost part. This is also the part that expands to

accommodate the growing fetus.

Cervix
 Allow flow of menstrual blood from the uterus into the vagina, and direct the sperms into the uterus during
intercourse. The opening of the cervical canal is normally very narrow.

Fimbriae
 Tube that are small, fingerlike projections at the end of the fallopian tubes, through which eggs move from the
ovaries to the uterus. The fimbriae are connected to the ovary.
 External Structures

Mons Veneris

 The mons veneris is a pad of fat tissues over the symphysis pubis.

 It has a covering of course, curly hairs, and the pubic hair.

 It protects the pubic bone from trauma.

Labia Minora

 The labia minora is a spread of two connective tissue folds that are pinkish in color.

 The internal surface is composed of mucous membrane and the external surface is skin.

 It contains sebaceous glands all over the area.

 Labia Majora

 Lateral to the labia minora are two folds of fat tissue covered by loose connective tissue and epithelium, the labia

majora.

 Its function is to protect the external genitalia and the distal urethra and vagina from trauma.

 It is covered in pubic hair that serves as additional protection against harmful bacteria that may enter the structure.

Vestibule

 It is a smooth, flattened surface inside the labia wherein the openings to the urethra and the vagina arise.

Clitoris
 The clitoris is a small, circular organ of erectile tissue at the front of the labia minora. Center for sexual arousal and

pleasure for females because it is highly sensitive to touch and temperature.

Skene’s Glands

 Also called as paraurethral glands, they are found lateral to the urethral meatus and have ducts that open into the

urethra.

 The secretions from this gland lubricate the external genitalia during coitus. Bartholin’s Gland also called

bulbovaginal gland, this is another gland responsible for the lubrication of the external genitalia during coitus.

 It has ducts that open into the distal vagina.

 Both of these glands secretions are alkaline to help the sperm survive in the vagina.
Fourchette

 This is a ridge of tissue which is formed by the posterior joining of the labia minora and majora.

 During episiotomy, this is the tissue that is cut to enlarge the vaginal opening.

Perineal Body

 This is a muscular area that stretches easily during childbirth.

 Most pregnancy exercises such as Kegel’s and squatting are done to strengthen the perineal body to allow easier

expansion during childbirth and avoid tearing the tissue.

Hymen

 This covers the opening of the vagina.

  It is tough, elastic, semicircle tissue torn during the first sexual intercourse.

Vagina

 Receives the penis during sexual intercourse and also serves as a conduit for menstrual flow from the uterus. During

childbirth, the baby passes through the vagina (birth canal).