Nursing Diagnosis

Assessment

Nursing Diagnosis

Desired Outcome

Nursing Intervention

Rationale

Evaluation

Short-term Goal

Independent

♀ Alterations from

No redness

♀ verbalize

♀ Vital signs,

normal may be

or

understanding

lochia

signs of infection,

anomalous

of risk

(character,

retained fragments

discharge

Objective

factors.

amount, odor &

or sub involution

is present

♀ c firm &

♀ identify

presence of

of the uterus.

at

contacted

interventions

clots), fundal

episiotomy

uterus

& demonstrate

height, &

line;

♀ NSD c

techniques

status of

lochial

episiotomy

to prevent

episiotomy were

discharge

♀ used

risk of

monitored.

has no

single pad

infection.

foul odor;

for 12 hrs

Long-term Goal

temperature

♀ T = 37°C

♀ achieve

♀ Proper perineal

♀ Appropriate self

is not

timely wound

care & hygiene

care of the

greater

healing.

were

perineum in

than 40°C.

♀ continue

reinforced.

postpartum patients

Subjective ‘ sakit gyud kaau ang akong tahi, di ko makalihok’.

Risk infection r/t episiotomy

to be free

reduces the risk of

of any

bacterial invasion.

symptoms of

Antiseptic feminine

infection

wash or clean warm

during

water may be used.

postpartum period. ♀ Emphasized

♀ Mothers who had NSD

early

are allowed to

ambulation &

ambulate 4 to 8 hrs

beginning

after childbirth.

postaprtal

Circulation of

exercises with

blood is promoted

resumption of

through regular

normal

movements thus it

activities as

helps in the

tolerated.

healing process; prevents constipation, circulatory problems & urinary

problems; promote rapid recovery; hastens drainage of lochia; improves GI & urinary function; & provide a sense of well-being.

Encouraged

♀ Vitamin C is known

to eat foods

to prevent

that are rich

infection; citrus

in protein &

fruits are rich in

vitamin C.

vitamin C. Protein

♀ Enough rest &

is needed for

sleep was also

tissue repair &

advised.

regeneration; meat products, nuts & legumes are rich sources of which. ♀ This promotes

healing by reducing basal metabolic rate & allowing oxygen & nutrients to be utilized for tissue growth, healing & regeneration.

♀ Antibiotics are Dependent used to treat & ♀ Intake of prevent infections antibacterial caused by medications susceptible such as pathogens in skin amoxicillin &

cephalexin as

structure

per doctor’s

infections.

order & advise.