Running Head: MATERNAL ASSESSMENT 1

Maternal Assessment Journal

Paige Bandera
Youngstown State University
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Paige Bandera

March 15, 2017

Trumbull Memorial Hospital/ Maternity

Beginning time: 3:00 pm Ending time: 9:00 pm

My postpartum clinical was a rewarding experience. I provided care to S.M. after her C-

section. She needed plenty of assistance as she was still early in her recovery; her C-section

happened the morning of my clinical. While providing S.M. with care I met four clinical

objectives.

“Integrates relevant concepts and theories of nursing and other disciplines into a plan of

care that maintains, and promotes the health and well-being of developing families and women”,

is the first clinical objective that I met. I met this objective by using previously learned postpartum

assessment skills. Followed by interpreting the data gathered from the patient’s chart and

assessment to meet the patient’s needs. For instance, I treated S.M.’s pain by assessing her pain

level and administering the necessary medication, with my instructor, based on assessment

findings.

The second objective I met was “evaluates how legal, ethical, political, economic, cultural,

social and safety issues impact the health care needs of the childbearing family and women

throughout the lifespan”. This objective was met by collecting data from S.M.’s chart to establish

a base understanding of her history. I gained a more in depth understanding by doing a

psychosocial assessment on the patient. The data from my psychosocial assessment and from the

charts enabled me to see what safety concerns needed to be addressed in regards to the patient and

her growing family.

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“Uses the nursing process to formulate a plan of nursing care, which incorporates holistic

health needs, developmental theories, family concepts and women’s health care for childbearing

families and women” is the third clinical objective that I met. I met this objective by performing a

complete postpartum assessment on S.M. and basing my subsequent care on my assessment

findings. Additionally, I used the data that I gathered later to form a written plan of care for the

patient.

The final objective that I met was “integrates relevant evidence-based nursing research into

the planning and implementation of nursing care for childbearing families and women”. This

occurred when I formed my written plan of care for the patient. I consulted my textbook to come

up with an appropriate nursing diagnosis for S.M. so it should reflect current nursing practice and

research. Also, all the care that I provided to the patient reflects current nursing practice because

we are being taught by nurses who are required to stay current to ensure patient safety.

Now I will summarize the care that I provided to S.M. and her newborn so that I may

evaluate it. I did not perform care for S.M.’s newborn except for observing when he ate. The

newborn was cared for by another nurse and spent a lot of time in the nursery while I took care of

his mother. The first thing I did was take vitals on S.M. which included a pain assessment. Since

S.M. was in pain I administered pain medication with my instructor. Shortly after administering

the pain medication I began my postpartum assessment on the patient. I did the postpartum

assessment in pieces so that I would not be disruptive of S.M.’s rest or time with visitors.

I took vitals on S.M. and reassessed her pain per unit protocol. I also did some patient

teaching on the pain medication she was receiving. Once the visitors were gone I worked with

Donna to remove the patient’s catheter. It was a good experience. After removing her catheter, we

helped the patient to the bathroom. After the patient got a little cleaned up we took her on a walk.
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She tolerated the walk very well. After her walk my clinical time was over and I thanked her for

letting me care for her.

To start off my evaluation I will state that I did the best that I could. I always try to provide

my patients with the best care that I am capable of. However, I was a little awkward when

performing certain aspects of my assessment. The hardest part was collecting the psychosocial

data because it involved asking personal questions. Next time I would wait to build more rapport

with the patient before asking such personal questions. Additionally, I would do more to care for

the newborn.

If I was the primary nurse from admission to discharge for S.M. and her family I would

gather as much data as possible. I would do a thorough assessment of S.M. upon admission and I

would follow unit protocols for assessing her throughout her stay. I would observe S.M.’s spouse

and family members so that I could gauge their needs as well. All that data that I gathered through

nursing care and observation would be utilized to form care plans that would keep S.M. healthy

while she was in the hospital. I would also use that data to refer the patient to resources outside of

the hospital to ensure the safety and health of S.M., and her family, after discharge.

Discharge planning for S.M. would include teaching her about the signs and symptoms of

infection so that she could monitor her incision. It would involve a review of how to care for a

newborn. Even though S.M. has three other children it is always helpful to review information. I

would go over infant safety for riding in the car, sleeping, bathing and interactions with siblings. I

would also go over cord and circumcision care. S.M. needs a referral to a daycare or she might

need to make arrangements with a family member so that she can take a break. S.M. is a

homemaker and that is very demanding; therefore, she is at risk for getting burnt out which would

not be healthy for her or her family.

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I learned from S.M., her family and my clinical experience in general. I practiced my

maternal assessment skills as well as other skills that are crucial to nursing; medication

administration and catheter removal. I did not have a good rapport with S.M. at first, most likely

because she was in pain, but once we established a rapport everything was great. I know it is

impossible to establish a good rapport with every patient, but it is something to strive for. It was

good to practice my skills and I enjoyed taking care of my patient.

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References

Lowdermilk, D. L. (2016). Maternity & Women's Health Care (11th ed.). St. Louis, MO:

Elsevier.