PostPartum Care Plan
Nursing Assessment of the Postpartum Patient
Date of data collection:___13 November 2014___
Patient initials _K.M.___ Age__28_ PP day _1__ (# days since delivery- 0, 1,2 3, etc)
Grav _4__ Para _3__ Term _3__ Preterm _0___ Ab_0__ LC___
Weeks gestation @ delivery (via EDC) _39.2____
Weeks gestation at delivery (from neonatal maturity rating/Ballard exam):_ 40_____
Date/time of delivery _12 Nov. / 1640_________
Labor onset - induced or spontaneous (circle one)
If induced: indication (why) and method (how) N/A Pt will be receiving a C/section.
Type of delivery: (vaginal - spontaneous or instrumental, C/section- (emergency or scheduled) _Scheduled C/section_______________
If instrumental or C/S- Indication: Pt has a Hx of 2 prior C/sections.__
AROM or SROM (circle) Time 1640 Color: Clear___ How many hours membranes ruptured prior to delivery? Membranes were ruptured for about 5min prior to delivery.__
Length of labor _N/A___hrs N/A___ min (from labor onset/ induction to delivery in hours)
Type episiotomy/laceration/or skin and uterine incision Transverse incision on the lower abdomen and uterine segment (Kerr incision)._
Pain or other Medication (analgesia) during labor _Stadol (Opioid analgesic), Ofirmer (Tylenol) ___
Anesthesia (local, epidural, spinal, general) _Spinal____
Estimated blood loss (EBL) at delivery 1300mL______
L&D Complications: Delivery: No complications with delivery of neonate documented in medical record. Pt denies having any complications during her delivery. Labor: N/A________________________________
Antepartum Risk factors: Pt was Rh-______________________________________________
Meds taken during pregnancy: Prenatal Vitamins___________
Prior surgical history C-Sections X2, Fibroid tumors removed. ____________________________________________________
Significant Obstetrical history: __Pt denies having any significant Obstetrical history.________________________________
Significant Gynecological history: __Pt admits
Date of data collection:___13 November 2014___
Patient initials _K.M.___ Age__28_ PP day _1__ (# days since delivery- 0, 1,2 3, etc)
Grav _4__ Para _3__ Term _3__ Preterm _0___ Ab_0__ LC___
Weeks gestation @ delivery (via EDC) _39.2____
Weeks gestation at delivery (from neonatal maturity rating/Ballard exam):_ 40_____
Date/time of delivery _12 Nov. / 1640_________
Labor onset - induced or spontaneous (circle one)
If induced: indication (why) and method (how) N/A Pt will be receiving a C/section.
Type of delivery: (vaginal - spontaneous or instrumental, C/section- (emergency or scheduled) _Scheduled C/section_______________
If instrumental or C/S- Indication: Pt has a Hx of 2 prior C/sections.__
AROM or SROM (circle) Time 1640 Color: Clear___ How many hours membranes ruptured prior to delivery? Membranes were ruptured for about 5min prior to delivery.__
Length of labor _N/A___hrs N/A___ min (from labor onset/ induction to delivery in hours)
Type episiotomy/laceration/or skin and uterine incision Transverse incision on the lower abdomen and uterine segment (Kerr incision)._
Pain or other Medication (analgesia) during labor _Stadol (Opioid analgesic), Ofirmer (Tylenol) ___
Anesthesia (local, epidural, spinal, general) _Spinal____
Estimated blood loss (EBL) at delivery 1300mL______
L&D Complications: Delivery: No complications with delivery of neonate documented in medical record. Pt denies having any complications during her delivery. Labor: N/A________________________________
Antepartum Risk factors: Pt was Rh-______________________________________________
Meds taken during pregnancy: Prenatal Vitamins___________
Prior surgical history C-Sections X2, Fibroid tumors removed. ____________________________________________________
Significant Obstetrical history: __Pt denies having any significant Obstetrical history.________________________________
Significant Gynecological history: __Pt admits