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ROADMAP FOR POST-CESAREAN POSTPARTUM NURSING CONSULTATION
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| Name: |
BD |
| SUS/ CNS Card |
Records: |
| Date: |
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NURSING HISTORY
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| Childbirth date: |
| Hospital name/ maternity of childbirth: |
| Duration of labor: _____hours |
| Premature rupture of membranes |
□ yes |
□no |
□ no information |
| If yes, how long has elapsed between rupture and childbirth: ___hours |
□ no information |
| Appearance of amniotic fluid: |
□ normal |
□ presence of meconium |
□ no information |
| Time of hospitalization: ___days |
| Cesarean section performed urgently: |
□ yes |
□ no |
□ no information |
| Reason for urgent Cesarean section: |
□ maternal hypertension |
□ fetal distress/meconium |
□ umbilical cord prolapses |
□ no information |
| Gestation |
□ single |
□ twin |
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| Gestational age at childbirth: ___weeks |
| Intercurrences in labor and childbirth: |
□ yes |
□no |
| If yes, which ones: |
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HEALTH EDUCATION GROUPS
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| PREGNANT WOMEN GROUP |
| Participation in the group |
□ yes |
□no |
How many meetings have you had? |
| SEXUAL AND REPRODUCTIVE PLANNING |
| Participated in the sexual and reproductive planning group |
□ yes |
□no |
| Contraceptive counseling |
□ yes |
□no |
| Contraceptive prescription |
□ yes |
□no |
| If yes, what method prescribed: |
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PUERPERIUM
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| Puerperium consultation |
□ by 7 days |
□ from 8 to 30 days |
□ from 31 to 42 days |
□ above 42 days |
| Feeding * |
□ appropriate |
□ inappropriate |
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| Ferrous Sulfate Supplementation |
□ yes |
□ no |
| Emotional state |
□ normal |
□ depressed |
□ bored |
□ sad |
| Hygiene |
□ daily bath |
□ intimate hygiene once a day |
□ sit baths |
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| Hygiene |
□ tidy |
□ not tidy |
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| Sex in the puerperium |
□ yes |
□ no |
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| COMPLAINTS |
| Fever |
□ yes |
□ no |
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| Pain underbelly |
□ yes |
□ no |
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| Surgical site pain |
□ yes |
□ no |
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| Urinary alterations (dysuria, polyuria...) |
□ yes |
□ no |
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| Vaginal secretion (appearance) |
□ yellow |
□ green |
□ colorless |
□ not applied |
| Another: |
| OBSTETRIC PHYSICAL EXAMINATION |
| General Vital Signs |
BP: |
Heartbeat: |
| LL Edema |
□ yes |
□ no |
If yes, how much +? |
| Breasts |
□ symmetrical |
□ asymmetrical |
□ turgid |
□ ingurgitated |
| Nipples |
□ flat |
□ protruding |
□ inverted |
□ sores |
| Abdomen |
□ flaccid |
□ distended |
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| Involution of the uterus (according to the time of puerperium) |
□ appropriate |
□ inappropriate |
□ not palpable |
| Surgical site |
□ without signs of inflammation |
□ local warm |
□ edema |
□ dehiscence |
| Surgical site secretion |
□ yes |
□ no |
|
| Secretion appearance |
□ serous |
□ yellow/purulent |
□ with blood |
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| Gynecological examination |
□ normal (cervix intact) |
□ altered (presence of lesion, warts) |
□ not done |
□ not applied |
| Lochia Appearance |
□ red (dark, after 2 days) |
□ yellow (after 10 days of delivery) |
□ white or serous (16th day postpartum) |
□ purulent (pathological) |
| Other findings: |
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NURSING DIAGNOSIS- ICNPHC
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| Vaginal discharge |
□ present |
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| Underbelly pain |
□ present |
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| Urinary elimination |
□ appropriate |
□ affected |
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| Body hygiene |
□ appropriate |
□ altered |
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| Food intake |
□ appropriate |
□ altered |
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| Breast Engorgement |
□ present |
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| Mastitis |
□ present |
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| Rest |
□ altered |
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| Skin trauma |
□ present |
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| Mom-child bond |
□ preserved |
□ affected |
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| Other diagnoses: |
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INTERNATIONAL CLASSIFICATION OF PRIMARY CARE- ICPC
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| □ Medical examination/health evaluation/complete |
| □ W17 Postpartum bleeding (postpartum bleeding criteria: frank bleeding during or up to 6 weeks postpartum). |
| □ W19 Signs/symptoms of breast/lactation (galactorrhea, ablation, weaning). |
| □ W70 Sepsis/puerperal infection (criteria: infection of the birth canal or reproductive organs up to 6 weeks postpartum). |
| □ W71 Infections that complicate pregnancy (maternal infections that complicate pregnancy or the puerperium). |
| □ W92 Birth of live birth (assisted delivery, pelvic delivery, cesarean section, dystocia, induced delivery, lesions caused by delivery, low-lying placenta during delivery). |
| □ W94 Puerperal mastitis (breast abscess; criteria: pain, inflammation of the breast at 6 weeks postpartum or during lactation). |
| □ W95 Other problems of the breast during pregnancy/puerperium (problems of the breast during the puerperium, sored nipple). |
| Other Classifications: |
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NURSING PRESCRIPTION
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REFERRALS
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| Signature and stamp of professional: |
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STITCHES REMOVAL
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| Date of stitches removal: |
| Surgical site appearance: |
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| Referrals: |
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| Evaluation of the surgical site for stitches removal: |
| Signature and stamp of professional: |
| *Feeding: take into account food routine recommended by the 10 steps of a healthy diet, with 3 meals daily (breakfast, lunch and dinner) plus two healthy snacks per day, following the recommendations by groups. |
| Recommendation: eat rice and beans every day of the week (at least 5 times a week). Drink 2 liters of water a day (6 to 8 glasses). Avoid industrialized products and salt. |
