Josh DeSalvo

St. Joseph’s Health Center

Start time: 0700 End time: 1300

2/14/17

On 2/14/17, I cared for a 27 year old female patient who was a Gravida 5 and, now, Para

5 who was 1 PP. She presented with normal vitals and was not in any pain. Her postpartum

assessment included data that her breasts were filling and her perineum was intact with only a

small first degree vaginal laceration. As the assessment progressed, upon fundal observation,

findings indicated a +1 fundus, displaced to the right of the umbilicus, and firm. After having the

patient void, the fundus returned to the U/U location and maintained its firm quality. Patient also

had lochia that presented as rubra with an amount equivalent to menses. The patient was

continent and independent in self-care with no evidence of complications.

Along with the mother, I had a baby boy patient who was born at 1853 of the previous

day. The baby was 7lbs and 6oz. with an APGAR score of 9/9. The baby boy was latching well

with breastfeeding but also received 80 mL of formula supplementation early in the morning on

the day of care. Baby received Vitamin K, Erythromycin, underwent a ritual circumcision, and

no complications were evident. Baby did have an irregular respiration pattern with an almost

inspiratory wheeze or stridor with auscultation. Baby did not appear to be in any acute distress

with skin color appropriate for ethnicity, no accessory muscle use with respirations, and no nasal

flaring. All other vitals presented as normal and mom appeared happy to see baby.
 As previously stated, the day consisted of assessments pertaining to mom and baby, along

with providing comfort care to mom and her husband through a complete linen change for mom

and a bed made for the husband to rest on. I also had the opportunity to administer the mom’s

ordered medication and provide her with information on what may be effective cold medicines to

take while breastfeeding her child. Through mom’s questioning, this facilitated the action of

providing her printable information on the particular topic, and an appropriate nursing diagnosis

for her would be readiness for enhanced parenting. Being able to provide patients with

information through hand-outs is often an under-utilized tool. This was a good opportunity for

me to make connections to the idea of helping patients have access to information and to help

them take an initiative in their own care. First, by having a physical copy of information, this will

help the patient to recall information in the future by having something to refer to and, second,

this provides the patient with confidence in the nurse that they will look to provide the most

accurate and factual information to them in order for the patient to receive the highest quality of

care possible.

Every day is a day to improve, and this particular day was no different. Unfortunately,

time management is a struggle of mine. I noticed that the predominant amount of my time was

focused on the mom and meeting her needs and I did not spend enough time effectively assessing

baby and monitoring his status. I could have been more intentional in caring for both patients. A

goal for next week is to have an already predetermined time schedule established where I will

spend at least a half hour performing my head to toe assessment, gathering vitals, and performing

daily cares for each patient. By keeping track of the amount of time I will have spent with each

patient, it will force me to have to see the other patient for the same amount of time as well,

based on the particular needs of the patient that is.