Critical Thinking Paper for OB

Running Head: POST PARTUM CTP

Post Partum Critical Thinking Paper

Grand Canyon University

Jennifer Fisher

February 25, 2011

Post Partum Critical Thinking Paper

            This critical thinking paper is based on J.K. a 32 year-old female. She had her first child on February 23, 2011 at the Estrella Banner Hospital. J.K. was 38 weeks along when her OB had her scheduled her to be induced on that Wednesday morning. J.K. was born and raised in Norway and met her husband in Phoenix, Arizona on a trip traveling the world with her best friend. She and her husband have been married now for nine years. J.K. has helped her husband J.B. raise his daughter (currently 13 years-old). Her little boy, C.B., weighed six pounds and five ounces, and was 21 inches long.

Health Perception/ Health Management

J.K. states that this baby boy was an accident, they had been trying for years to have a baby. They went through two rounds of in-vitro fertilization that was unsuccessful, and about a year or so after J.K. and J.B. stopped trying to have a baby, she became pregnant. Due to her and her family’s busy schedule, J.K. never took a prenatal class; however, she stated that she read many different birthing books in order to become well educated about the pregnancy and how to properly manage her body during this time. She also had been talking to her mother and sister who have both been through several pregnancies in order to further comprehend what her body was going to go through and how best to care for herself during the pregnancy.

Role Relationship

Currently J.K. is a stepmother, wife, teacher, friend, and daughter. With this baby boy, she is greatly looking forward to being a mother of her own child. She is, however, nervous about being able to love her son just as much as she does her stepdaughter, and not neglect either of the children. Her husband’s daughter has lived with them since she was four years old (currently she is 13 years old). J.K. and her stepdaughter are extremely close, largely due to J.K. being there for the majority of her childhood. The step-daughter was present at the hospital during the delivery, however, she was not allowed to be in the room during the delivery. J.K. stated that the reason she did not want her stepdaughter in the room during the delivery was because J.K. did not know how she was going to react to having the baby and did not want to scare her stepdaughter. J.K. also wonders how having this baby will affect her relationship with her husband; she hopes that ultimately it will make their bond grow all the stronger.

Nutrition

J.K. has never been overly concerned about choosing healthy and nutritional foods when she ate, until now. She is currently taking calcium supplements, as well as, drinking some milk to help increase her calcium intake. She does not particularly enjoy drinking milk so the calcium supplements are used as way to increase the calcium intake in her body. She was also taking prenatal vitamins on a daily basis. J.K. is also eating an increased amount of fruits and vegetables. She states that for snacks instead of eating junk food she has substituted them for slices of apples or a cup of sliced fruit or vegetables. Although, she felt guilty and admitted to caving to eat Twizzlers and cake with her second grade students on their hundreth day of class. Her protein intake has also been increased during the pregnancy. During her first trimester, her nutritional intake was not as adequate as it should have been, according to J.K. She would be a portion of the way into eating her meal, then would become full, so her intake became decreased. During the second and third trimester her appetite has been very healthy, and she is constantly eating. She has gained 40 pounds since the start of her pregnancy. Currently, she is now getting uncomfortable in her abdomen, especially when she tries to eat.

Elimination

Early in her pregnancy J.K. was regular with her eliminations. She typically has one bowel movement a day, sometimes two or three, becoming more consistent as of lately. As J.K. got closer to her due date she complained of experiencing polyuria. She said she had been getting up approximately every two hours to urinate throughout the night. During the day, she could only manage about two hours or less before having the urge to urinate; this was largely because of the increased walking she was doing during her workday. J.K. has been able to void twice in the time of 13 hours since having her baby. She is largely afraid of possible infection from the episiotomy and pain from urinating.

Sleep/ Rest

J.K. shares a bed with her husband in the master bedroom upstairs. Prior to her pregnancy, she typically slept anywhere from six to eight hours a night. During her first and second trimester she didn’t have any trouble sleeping. However, towards the end of this third trimester, her sleeping habits were being interrupted severely by having to get up for urinary frequency, increased lower back pain, and the baby moving around frequently. J.K. likes using the body pillows when she sleeps, it increases her comfort level. She and her husband are a little nervous about the lack of sleep that the both of them will accrue with a new infant in the house.

Activity/ Exercise

J.K. does not have an exercise routine or regimen. As a second grade teacher she is constantly moving and lifting. The combination of that, her husband’s busy schedule, and her stepdaughter’s very active lifestyle, J.K. does not always have the time to set aside for a consistent workout. She does, however, have a recumbent bike available for her use at the house. J.K. started to use the recumbent bike just before she became pregnant. After becoming pregnant she stated that she stoppped using the bike because she was unsure of how it would affect the fetus. The nurse and I were able to educate her that it was perfectly fine for her to have worked out during pregnancy using the recumbent bike. Her husband does not have a workout regimen either. He is currently a recruiter for the National Guard and only works out when it is necessary for their fitness tests.

Cognitive/ Perceptive

J.K. has her bachelor’s degree in education; this degree has allowed her to teach at Heritage Elementary School. At Heritage, J.K. moved from teaching kindergarten last year, where she had taught for the past three, to teaching second grade at their main campus in Glendale. She originally obtained her degree in Norway. J.K. was thinking of going back to get her master’s degree before she got pregnant, however, she is planning on going back after her son is a couple years old. J.K. states that she is an auditory and visual learner. J.K. and her husband make all the major decisions for the family together; if a disagreement occurs, then they compromise. When J.K. first got married her husband, J.B., was in charge of their finances, but after he left for his second tour in Iraq she became in charge of major financial decisions. She is ecstatic to have a son of her own and to continue growing their family together. J.K. stated that she was a little nervous, not so much about having a baby at home but about her episiotomy and being able to care for her family. Her husband was present during the delivery. J.K. is hoping that her mother will be able to come in March from Norway to help her and her husband with the baby.

Self Perception

J.K. is excited to have a baby of her own, especially after trying for so long and having no success until now. She is extremely close with her mother and sister and is slightly disappointed that neither one of them could be there during her son’s birth. Her mother, they are all hoping, will be arriving in Phoenix on March fourth to help J.K. and her husband. J.K. is a very social person, extremely easy going, gentle, caring, and intelligent. She does not really like to cook, but does it because it makes her husband happy. She seems very positive about being pregnant and how everything had progressed during her pregnancy. She was nervous about the pain during birth, hearing that it is the most excruciating kind of pain a woman can face. She is now nervous about her episiotomy and caring for her family. J.K. has been able to take maternal leave from work long enough to adjust to having him at home. She then will have about a month left of work to finish before her summer break begins. Her husband is also trying to get time off work to help at home.

Sexuality/ Reproduction

J.K. stated that this pregnancy was completely unplanned. She went through in-vitro fertilization (IVF) twice trying to get pregnant. Both times she went through the IVF were unsuccessful. Prior to her IVF treatment and pregnancy, J.K. was on birth control. After this birth she is 95 percent sure that she will go back onto birth control. J.K. stated several times how much she was hoping to have another baby after this one, however, she does not think it will likely happen because of how hard it was to get pregnant this time. She is still sexually active and plans to be while her child is growing.

Coping Stress

Having a new infant in the household is an extremely stressful situation in their lives. Their routines will completely change to match that of the baby’s. Prior to the pregnancy, J.K. could live comfortably with the finances that were brought in to their family. Now, she is a little nervous about finances due to having the baby and the uncertainty of having a job next year (being in the education system). However, J.K. has a savings system set up for her family. Her reaction to stress is to not eat, especially when she is under a great amount of stress. J.B., her husband, resorts to smoking when he is extremely stressed. Neither one of these are effective or healthy coping mechanisms. J.K. and her husband were taught by the nursing staff activities that everyone in the family may participate in as stress relieving events.

Beliefs/ Values

J.K. was raised in Norway, and grew up attending a state church. When she came to Phoenix, settling here with her husband, they tried several churches but never found one that quite felt like home or like the ones she grew up in. One of her top priorities with her son is to teach him morals and respect of others. She practices her faith at home and when J.K. visits her home in Norway, she goes to church with her immediate family.

Postpartum Physical Exam 

History: Gravida__1____	Para____0________	Type of delivery: check Vaginal__X__ or C/B_____
Physical Assessment Textbook NORMS	Student Observations To be filled in during clinical	Only fill in what is abnormal and why it is abnormal
Appearance Fatigue is normal. Pt may appear to still be pregnant as abdomen will protrude. Stretch marks, or striae may be present General Survey	Patient J.K. was awake and oriented. Upon entering the patient’s room she was awake talking with her husband and holding their baby boy. J.K. was minimally fatigued. She had a rounded abdomen with stretch marks present.
Appetite If breastfeeding mom’s need 2700 kcal/day and drink plenty of liquids If C/S: mom’s will be very hungry since NPO the night before If vaginal birth: usually hungry but fatigued due to lightening and delivery	J.K. is breastfeeding her infant, her dietary habits include an increase in fruit, protein, and calcium supplements.  She is currently not drinking coffee instead she has been drinking about two liters of water per day.
Weight Should gain 25-35 lbs and only eat 200-300 calories more than usual Post-delivery: loss of 12-15 lbs	J.K.’s pre-pregnancy weight is 135 At the end of her pregnancy J.K. weight is 175 (weight gain of 40 pounds) Her post pregnancy weight was not taken.	J.K. has gained over the 25-35 pound weight gain for pregnancy. At the end of her pregnancy she had gained a total of 40 pounds.
Temperature 36.1-38 degrees Celsius	36.7 degrees Celsius
Pulse 60-100 bpm	80 beats per minute
Blood Pressure 120/80 Assess for orthostatic hypotension	125/85 There was no evidence of orthostatic hypotension present in J.K.
Breast & nipples Nipples range from inverted, flat, or everted. Within the first 72 hours, breasts will be rounder and swollen from milk. Firm, tender, and warm to the touch. Soreness is normal after breast feeding. Skin, nipple, and areola should be intact, with no cracks or bleeding.	J.K.’s breasts are tender. Her nipples are everted firm, and warm to touch. No cracks or bleeding are present. The infant is latching onto J.K.’s breasts with no problems.
Fundus      Status: firm   Involution of 12 hr: 1 cm above umbilicus. It descends 1-2 cm every 24 hrs. Should not be palpable after 2 weeks	The patient’s fundus is firm, located medially, and one centimeter above the umbilicus.
Muscle tone of abdomen It is normal for woman to look pregnant as abdomen stills protrude. Abdomen should be round and soft. Return of muscle tone depends on several factors but mainly on the adipose tissue present	Patients abdomen is still protruding, looking like she is 6 months pregnant.  Her abdomen is soft with minimal striae present.  Patient states that her lower abdomen is really sore and its harder for her to move around due to her incision from her C/S.  This is normal for a C/S.
After pains Breastfeeding can increase and intensify cramping. A feeling of uncomfortable cramping after birth is normal	J.K. is experiencing cramping (pain scale 6 out of 10). Breastfeeding is a new concept and a little odd, as stated by the patient. She states that there is a minimal amount of uncomfortable feeling, however, it is bearable.
Lochia    Characteristics:    Rubra: clots, bright red blood    Serosa: decreased flow and clots, appears brown, old blood color    Alba: mucous color, yellow to clear. It has bacteria, serum, and leukocytes    Progression: Rubra last 3-4 days, serosa 21-30 days, and alba 8-14 days	The patient is having a moderate amount of lochia rubra. There are no foul odors present.
Perineum Erythema edematous, tender and sore. If  episiotomy present note any signs of infection. If any stitches present make sure they are CDI.	General observation: ¨ Intact ¨ Lacerations Degree of ¨ Episiotomy	J.K. has an episiotomy that is a partial third degree located medial laterally.
Abdominal incision Painful, sore, CDI, with no signs of infection. Well approximated	N/A patient delivered vaginally.
Voiding pattern: Soreness can lead to hesitancy and therefore bladder extension. Intense dieresis lasting 12 hours to 3 days Urine characteristics: clear red color, proteinuria	J.K. has urinated twice since giving birth 13 hours ago. She is nervous about urinating since she has an episiotomy. J.K. is scared of causing an infection.
Bowel pattern: Should have a BM 1-3 days. Fear of pain may cause hesitancy which can lead to constipation Hemorrhoids: Venous protrusion through anus is common but it may go away after time	J.K. has had one bowel movement since giving birth. She is nervous about having a bowel movement because of causing an infection or ripping the stitches that have closed her episiotomy.
Extremities     Homan’s sign: negative    Edema: non-pitting edema on extremities is common	When Homan’s sign was performed on J.K. it was negative and no signs of non–pitting edema were present.

Postpartum Diagnostic Data

Diagnostic Data NORMS	Observations To be filled in during clinical May not have been drawn on the patient	Fill in what is abnormal  why abnormal Critical think about lab values for this patient and identify any issues or potential problems
Blood      Type and Rh Type and Rh Types: A, B, AB, or O Rh: positive or negative	J.K. has a blood type of B+	Various blood types:
Hgb 12-15 g/dl	11.8g/dL	Her hemoglobin is below normal due to blood loss from J.K.’s delivery.
Hct 37-46%	36%	J.K.’s hematocrit is also low due to her blood loss from the delivery.
WBCs 5-15	14
RBCs       3.8-5.5	3.7	This lower RBC is due to pregnancy.
Platelets 150-400	200
Coagulation factors (PT, PTT, Fib, FSP) PT: 12-14 seconds PTT: 18-28 secons aPTT: 30-45 seconds FSP: < 10 mg/L	When looking through J.K.’s chart there were no laboratory results noted for coagulation factors.
Urine Color and consistency: clear yellow, no foul odor. 150 ml. hr minimum	J.K. urinated consistently every two hours. Her urine was a clear yellow coloring with no abnormal or foul odors noted.
Specific gravity       1.002-1.030	1.010
Sugar 70-110 mg/dL	95mg/dL
Protein 6-8 g/dL	6g/dL
Other
Rubella status Immune	Immune
HIV Negative	Negative
Group Beta Strep (GBS) Negative	Negative
Hepatitis B Surface Antigen (HBsAg) Negative	Negative
VDRL/RPR Syphilis - Negative	Negative