Postpartum Health Assessment

Alex Clark & Madyson Pickett

Youngstown State University Nursing

NURS 3731L

Ashley Gentile

March 29, 2022

 We were assigned to provide care to a 26 year-old female after a cesarean delivery of her

2nd child on 3/29/22 at 1939. The patient has a gravida of 3, with 2 full term babies and 1

spontaneous abortion. The mother’s first baby was delivered via C-section so this was a

scheduled delivery due to the possible risks of a vaginal birth after cesarean. Risks from a VBAC

include rupture of the uterus which could lead to excess blood loss and infection. The baby boy

was 39 weeks and 1 day gestation. He was 8 pounds and 8 ounces and measured 20 inches. He

had an APGAR score of 9 both at 1 and 5 minutes. Our nursing plan for the day included passing

medications, performing a thorough assessment, and assisting the patient with ambulation and

showering.

We introduced ourselves to the mother and father to build a rapport and to promote a

relationship where they felt comfortable asking questions and voicing their concerns. Once we

felt the patient was comfortable with us, we began a postpartum health assessment. The

assessment started with questions regarding this pregnancy. The mother stated the pregnancy

was planned with her fiancé and she was taking oral contraceptives at the time. The patient and

her significant other went to their OB doctor for 16 prenatal care visits. A few nonstress tests

(NSTs) were performed throughout her pregnancy due to decreased fetal movement and the

baby’s cord placement close to the neck. The mother and father did not attend childbirth classes

because she stated they raised their first child and had no problems.

The patient’s vital signs were obtained first thing in the morning. Her blood pressure was

120/87 (right upper arm), temperature was 98.5, respiratory rate was 16, and heart rate 98 beats

per minute. We performed a BUBBLE assessment of the mother. Her breasts were nontender,

fundus was midline and 1 breath below the umbilicus, and she had a moderate amount of rubra

bleeding with a few small clots. Her last bowel movement was on 3/28/22. Her bowel sounds
were active in all 4 quadrants, and the perineum was intact. The patient has a low transverse

incision on her abdomen, edges are well approximated with sutures intact, negative for odor or

drainage, and the surrounding skin was slightly red. We removed the dressing with the nurse

present, and she explained for us to just apply a peri pad with some tape after the patient’s

shower so that the incision would not be irritated by any clothing.

Upon the assessment of the patient’s cardiovascular system, we noted trace edema of the

upper & lower extremities bilaterally and face, all pulses were 2+, and capillary refill less than 3

seconds in all extremities. Edema is common after birth for most mothers, but should still be

monitored closely. Therefore, a nursing diagnosis for this patient was excess fluid volume.

Nursing assessment includes monitoring the patient’s respirations, blood pressure, heart rate,

intake and output, and assessment for edema. The use of compression stockings and early

ambulation are used to promote venous return. Our patient was also at risk for injury due to the

decreased bladder sensation and tissue trauma. We monitored the clients voiding pattern closely

and assessed the surgical incision for redness, edema, ecchymosis, discharge, and approximation.

Incorporated into the care plan for risk of injury were early removal of indwelling catheter,

encouragement of early mobilization, use of pneumatic compression devices/compression

stockings, and use of abdominal binder.

Based on our assessment, the mother’s stage of growth is maternal identity and is

outlined by Mercer (2004) as “having a sense of being in her role, along with a sense of comfort

about her past and future.” Upon assessing her nutritional status, we determined that the patient

needed to eat smaller frequent meals with more nutritious foods, instead of the unhealthy food

she was eating throughout the day. She was getting around 7-8 hours of sleep each night with

about 1 nap per day, which is an adequate sleeping schedule. She has a healthy coping
mechanism which is getting long, hot showers. After quitting her job as a medical assistant at

Southwoods, she is a stay at home mother who has a close and loving friendship with her fiance

and children. Occasionally if she has time, she enjoys reading books, but most of her time is

spent caring for the children. The patient stated that she enjoys being at home with her children

and does not regret quitting her job. She has no spiritual, religious, or cultural beliefs or

background. The mother had no questions related to past, current, or future medical services.

Overall, this patient was wonderful and very cooperative throughout the clinical day!
 References

Mercer, R. T. (2004). Becoming a mother versus maternal role attainment. Journal of Nursing

Scholarship, 36(3), 226–232. https://doi.org/10.1111/j.1547-5069.2004.04042.x