Assessment Nursing Diagnosis Desired Outcome Nursing Intervention Rationale Evaluation

Subjective Risk infection r/t Short-term Goal Independent ♀ Alterations from No redness
episiotomy
‘ sakit gyud kaau ang ♀ verbalize ♀ Vital signs, normal may be or
akong tahi, di ko
makalihok’. 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 is not

♀ Appropriate self
timely wound care & hygiene greater
care of the
healing. were than 40°C.
perineum in
♀ continue reinforced. postpartum patients
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.