Postpartum History

Room 7324 Client Initials TH Age 34

Allergies PCN

Admission PCV 41.0 % Postpartum PCV 31.2%

MD Anderson

Type of Delivery Cesarean Section EBL approx. 700 mL

Episiotomy or lacerations none

____male __X__ female Weight of infant 6 lb. 2 oz.

_X_ breast _____ bottle

Scheduled meds: Colace

PRN meds: Pepcid, Reglan, Tylenol, Maalox, Americaine,

Dulcolax, Decadron, Dilaudid, Benadryl, Tucks, Robutussin,
Epifoam, Motrin, Toradol, Milk of Magnesia, Morphine,
Nubain, Narcan, Zofran, Mylicon, throat lozenges

Last dose of Pain meds (prior to my arrival): Toradol 30

mg IV (0545 on 9/15/09)

Diet: Regular

Assessment data
Fundus: fundus is firm with uterus midline,
approximately 1-2 fingerbreadths (fv) between the
umbilicus and the top of the fundus; minimal
discomfort upon palpation
Lochia: scant to light, wine-colored, lack of notable
clots or odor
Perineum: lack of hemorrhoids, edema, bruising,
redness, drainage, hematoma or bleeding
Breast: tissue soft; nipples are without signs of
cracks, blisters, reddening, inversion, bruising
or bleeding
Epidural site: site is without signs of infection; no
redness, edema, erythema, or discharge
Voiding: bladder not palpable; spontaneous voiding
with adequate bladder emptying AEB approximately
1300 mL of blood-tinged urine out (8 hr period);
 lack of urgency, frequency, or inability to void
Neurological: AA0x3; patient denies headache, visual
changes; PEARL
Circulatory: Skin warm/dry, color normal for
ethnicity; denies chest pain/shortness of breath;
no suggestion of murmur upon auscultation;
Integumentary: skin intact with breakdown, bruises, or
petechiae; no edema to extremities, pedal pulses
strong and equal

If C/S:
Lungs: clear bilaterally upon auscultation; patient
denies dyspnea, cough, or tachypnea
Incision: sutures remain dry, intact, and clean; lack
of erythema, edema, warmth, tenderness, seropurulent
drainage, or wound separation
Bowel sounds: normal bowel sounds heard in all 4
quadrants; abdomen without distention
Flatus: passing flatus without report of gas pains
Ambulation: while pushing bassinet down hallway on
unit patient’s gait visualized as steady but slow;
patient without assistance or difficulty to restroom;
observed ambulation around room without evidence of
severe pain
I/O: adequate consumption of water throughout shift;
roughly equivalent output, without sedimentation,
straw colored
Foley: patient shows no signs or symptoms of urinary
tract infection following removal of catheter at 0545
on 09/15/09
IV fluids: Lactated Ringers at 125 mL/hr prior to
removal of IV at 0900; site without redness, warmth
or drainage