AM Health
6/7/23, 8:52 AM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
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Focused Exam: Postpartum Care Results | Turned In
Humanistic Nursing Practice - Childbearing Families - Maternal Health - Summer 2023, NUR 3590
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Overview
Transcript
Transcri
pt
Subjective Data Started: Jun 07, 2023 | Total Time: 108 min
Collection Objective All Lines Interview Questions (43) Statements (8) Exam Actions (33)
(84)
Data Collection
Education & Good morning Ms. Hernandez. My name is Lindsey and I will be
your nurse today. 06/07/23 7:14 A
Empathy
Documentation
Hello!
Status Report
Que
Care Plan How are you feeling today?
06/07/23 7:15 A
Program Competency
Progress I'm . . . actually really tired. Sleepy. A little dizzy, too. And there's
some pain in my abdomen.
Que
How bad is the pain on a scale of 1-10 where 10 is the worst?
06/07/23 7:16 A
It's not a lot of pain, really . . . it's more uncomfortable. I'd say my
pain is a 2 or 3 out of 10.
Que
have you started breastfeeding yet?
06/07/23 7:18 A
Beatriz hasn't . . . started nursing yet. We tried earlier, but she
isn't latching.
Que
Have you felt your uterus contract since giving birth to Beatriz? 06/07/23 7:19 AM
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, 10/16/24, 11:54 Gloria Hernandez PostPartum Shadow
AM Health
6/7/23, 8:52 AM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
No, I don't think I've felt it contract But it's hard to be sure, with the epidural.
Do you feel any wetnesss in your vaginal or perineal area?
I haven't felt any wetness, but I can't feel much down there yet.
Assessed vitals
Assessed lab results
Assessed lab results
Assessed IV site
Inspected abdomen
Inspected appearance
Inspect legs
Auscultated breath sounds: Breath sounds clear in all areas, with no adventitious sounds
Auscultated heart sounds: S1 and S2 audible, with regular rate and rhythm, and no extra sounds
Assessed Lochia: Red colored with large, irregular clots. Peripad is completely saturated
Assessed Lochia: Red colored with large, irregular clots. Peripad is completely saturated
Assessed fundus: Located midline, boggy, and with no bladder distension
Performed fundal massage: Duration of 2 minutes, bleeding has stopped. No
additional clots expelled, and uterus has contracted
Measured blood loss
Notified charge nurse
Applied oxygen
Increased oxytocin
How are you feeling?
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