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Name:Carmella Anggana Chief Complain: labor pains

Attending Physician: Dr. Ortiga Diagnosis: Post normal spontaneous delivery

Room and Bed No. : 253-2

Date December 7 2011 @ 3pm 3-11 shift

Cues Subjective:

Need H E A L T H P E R C E P T I O N H E A L T H M A N A

Nursing Diagnosis

Objectives of Care

Nursing Interventions nterventions 1.) Reassess the characteristics of the wound, including color, size, drainage, and odor. these data provide information on the extent of damage. Color of tissue is an indication of tissue viability and oxygenation. Odor may arise from infection present in the wound; it may also arise from necrotic tissue. Wound drainage or exudates is a normal part of wound physiology and must be differentiated from pus, which is an indication of infection. Purulent drainage from the injured area is an indication of infection. 2.) Inspect the incision every shift using the REEDA (redness, edema, ecchymosis, discharge and approximation) method. frequent assessment can detect signs and symptoms of possible infection, complications. 3.) Identify signs of itching and scratching. the patient who scratches the skin in attempt to relieve intense

Evaluation December 7, 2011 GOAL MET. @11pm Within my 8 hours span of care, my patient was able to: a. learn and be aware of the possible danger signs of the wound and various ways on how to give skin care to her perineum, such as washing the perineum thoroughly with warm water, and verbalize importance of doing so. b. prevent any further complications or injury from happening by not engaging in any strenuous activities and moving in a gentle manner. c. ambulate (e.g walking to fix her things as well as exhibiting a calm attitude towards her condition with regards to the episiotomy.

Objective: : Median episiotomy with repair of 2nd degree laceration Vital signs: CR- 77bpm PR-75bpm RR-20cpm TEMP-36.5 BP- 100/70mmHg Lochia rubra noted in scanty amount 39 1/7 weeks AOG, PROM, G1 P1

Impaired skin Within my 8 hours span integrity related to of care, my patient will skin breakdown be able to have timely secondary to wound healing/repair episiotomy by: a. demonstrating understanding and An episiotomy involves a surgical importance of self care incision on the activities; tissue between the b. identifying possible vagina and the anus danger signs of the or off to the side of wound and refer for the vagina to any unusualities noted, enlarge the outlet. such as pain, etc.; Research suggests c. not exhibiting any that an episiotomy other complications when combined with (e.g infection, edema, instrumentation redness, etc) and makes it more likely unsusualties in the that the woman will vital signs; have deep perineal d. being informed of tears and normal various ways of perineal tears heal perineal skin care more quikly than routine; and deep perineal tears. e. perform skin care In clinical practice, behaviours / methods research has shown and maintain those that the incidence of practices in an

G E M E N T

major perineal trauma is more likely to happen if a midline episiotomy is done. Additional complications associated with episiotomy are blood loss, infection, pain, and perineal discomfort that may continue for days or weeks past birth, including painful intercourse. Bibliography: London, Marcia L. et al. Maternal & Child Nursing Care. Second Edition. Upper Saddle River, New Jersey: Pearson Education, Inc. 2007. Pp. 550

outpatient basis.

itching may open skin lesions and d. the patient also increase risk for infection. verbalized that after the 4.) Reassess the vital signs of the interview, she would patient provide means to stabilize change the napkin she had vital signs, such as TSB, etc. on, which is already an increase in temperature, soaked with blood and pulse and blood pressure may other discharges (lochia). indicate infection and other complications. Knowing unusualities in the vital signs will help us perform interventions tro help alleviate the patients condition. 5.) Caution patient not to touch the wound. prevents contamination of wound by microorganisms. 6.) Keep client's skin clean and dry and may lubricate as much as needed. will reduce risk of irritation and skin breakdown. 7.) Instruct and assist the patient with general hygiene, including hand washing and toilet practices. proper hand washing is the most effective method of disease prevention. Bacteria from hands can easily contaminate other areas. 8.) Teach the patient how to apply and remove a maternity pad. Tell her to apply a clean pad from front to back and to remove a soiled pad from back to front. this is to decrease the risk of contaminating the vaginal area with stools.

9.) Suggest to the patient to change diaper, napkin, and other protective wear every four hours. to relieve moisture and prevent the proliferation of bacteria. 10.) Suggest to the patient to avoid strenuous activities. shear force or pressure may induce more damage to the skin. 11.) Help the patient to assume a comfortable position. to help reduce tension at the incision site by relieving pressure to it. 12.) Encourage diet that meets the nutritional needs. a high-protein, high-calorie diet may be needed to promote healing. 13.) Instruct the patient or watcher in proper care of wound (i.e. cleansing, dressing, and application of topical medications) teaching the proper care of the wound to the patient and watcher increases their ability to manage therapy independently. 14.) Instruct the patient and watcher in the possible danger signs and symptoms that should be reported to the physician immediately. These include: a. Incisional drainage b. Unusual vital signs c. Increased discomfort at the episiotomy or incision site d. Reddened or warm skin

surrounding the episiotomy or incision site. prompt reporting of danger signs and symptoms may help prevent major complications. 15.) Administer antibiotic as indicated. R: to treat specific infection and enhance healing. Evaluation

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