9-11-14 1035am Patient sitting up in bed, watching television. Respirations even unlabored.

Breasts are
symmetrical, soft patient denies feeling of fullness or tenderness. Patient is bottle feeding newborn,
taught importance of well fitting, snug bra and comfort measures to relieve breast discomfort when milk
begins to come in. Patient verbalized understanding of teaching. Uterus firm U/2 located midline. Last
void was 15 minutes prior to assessment, stated it was a medium amount with no burning. No post
surgical bowel movement accomplished, bowel sounds active in all 4 quadrants. Low transverse incision
is open to air staples intact, no redness or warmth at site. Patient complaints of mild tenderness in area
are expected and WNL. Colace administered 45 minutes prior to assessment. Lochia rubra, moderate
amount, with foul odor. Discussed the importance of cleaning perineum with perifoam with every peripad change. Patient verbalized understanding of teaching. No pain in lower extremities nonpitting
edema bilaterally in feet. Ambulation encouraged, patient verbalized understanding. Patient reports
feelings of sadness and anxiety concerning newborn baby in Charleston NICU. Affect consistent with
conversational topic. Sat with patient while she called to check on infant, discussed her support
network and coping strategies. Patient stated feeling less anxiety and more optimistic. Offers of
pastoral or social service collaboration refused. All standard safety measures in place. VHarris, SN