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13 Cards in this Set
- Front
- Back
Subjective
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Ask about pain control, diet (and if tolerating), nausea, vomiting, flatus, ambulation, voiding, vaginal bleeding (lochia), and breastfeeding (and how it is going and long-term plans). Ask about post partum birth control plans and circumcision for male neonates.
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Objective Components
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VS and I/O’s:
CV: LUNGS: ABD/Incision: EXT: Labs: |
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Key to I/Os
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Include UOP over 24hrs (calculate rate per hr).
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Typical Labs
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If POD #1. Typically CBC.
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A&P Sentence
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Age, G_P_ _ _ _ POD # s/p (type of C/S) for (indication), doing well.
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Components of Plan
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CVS/Heme:
GU: FEN/GI: Neuro: Proph: Breastfeeding: PPBC: post partum birth control plan |
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Example CVS Heme:
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AFVSS. CBC appropriate for EBL (or pending)
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Example GU
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Adequate UOP overnight, plan d/c foley, and await void
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Example FEN/GI
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HLIV (hep-lock IV); Advance diet to general (ADAT)
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Example Neuro
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transition to PO pain meds
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Example Proph
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SCDs, encourage ambulation
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Example Breast-feeding
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Lactation consultant PRN
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What else might you include at end?
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** Include blood type and rubella status in your note- pt may need Rhogam or MMR postpartum
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