NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Pain related to uterine After 30 minutes to 2 Independent: After 2 hours of nursing
 “I’ve been cramping and hours of nursing 1. Promote perineal Decrease discomfort intervention the patient
breastfeeding Sara increased vaginal intervention the patient exercise and was able to experience
every 4 to 6 hours discharge as will experience lesser comfortable sitting lesser pain and above a
with no problems, and evidenced by pain and above a position such as: tolerable level as
she seems to be fine.” complains of pain on tolerable level as manifested by:
palpation of lower manifested by:  Kegel’s exercise Three or four times a
 “I’ve been so tired for abdomen and  Sitting position day with five times  Fever went down to
the past few days, increased lochia flow  Reduces associated succession reduces 37.5°C
even though I’m with brownish discomforts discomforts and  Have an
getting sleep, but I discharge.  Refocuses client’s improves circulation in understanding about
haven’t been hungry.” attention, promotes the area and decrease the duration of post-
positive attitude, edema. partum discomforts
 “My lower belly is very and enhances  Knows how to do
sore. I also noticed comfort Before sitting squeeze proper breathing
that my vaginal  Promotes sense of buttocks together and exercises as
discharge has general well-being sit with that position demonstrated by the
increased and and enhances reduces physical patient
changed back to a healing. Alleviates discomfort.
brownish color. It’s discomfort After 4 hours of nursing
smellier now, too.” associated with 2. Tell patient that the The patient may fix her intervention the patient
chills. pain and discomforts mind frame about the was able to experience
Objective: usually last more than 3 pain, this in return will lesser pain and above a
After 4 hours of nursing days. lessen the perception of tolerable level as
 Small amount of intervention the patient pain and her anxiety. manifested by:
lochia, brownish with will experience lesser
a strong foul odor, on pain and above a 3. Instruct patient to do Facilitates relaxation  Pain scale of 5/10
pad tolerable level as breathing exercises.  No facial grimace
 Complains of pain on manifested by: noted
palpation of lower 4. Assessed location and Helps in the differential  Calm and
abdomen  Pain scale of at least nature of discomfort or diagnosis of tissue cooperative patient
 No bladder distention 5/10 pain, rate pain on a 0– involvement in the  Demonstrated
noted  Slight irritability and 10 scale. infectious process. proper sitting
 Uterine fundus most of the time is techniques/position
nonpalpable calm 5. Assessed for non- Non-verbal cues such as
 Lung sounds clear  Less complaints of verbal pain cues. crying, grimacing, or
withdrawn behavior
  Urine clear pain after may indicate pain.
 Urinalysis findings administration of Therefore, the goals
normal medicine Promotes sense of were met.
6. Provide instruction general well-being and
Vital Signs: regarding, and assist enhances healing.
with, maintenance of Alleviates discomfort
Temperature cleanliness and warmth. associated with chills.
 100.9°F (oral) / 38.2°C
Pulse Reduces muscle fatigue,
 110 beats/min 7. Change client’s promotes relaxation and
Respiratory Rate position frequently. comfort.
 14 breaths/min Provide comfort
Blood Pressure measures; e.g., back
 118/64 mmHg rubs, linen changes.
Heat promotes
8. Apply local heat using vasodilation, increasing
heat lamp or sitz bath as circulation to the
indicated. affected area and
promoting localized
comfort.

Reduces associated
9. Administer analgesics discomforts of infection.
or antipyretics.
Pain is a lot easier to
10. Encourage the control before it
woman to ask for pain becomes severe.
medications before the
pain becomes
severe/intolerable.

Dependent: To relieve pain as fast as

1. Administer analgesic 30 minutes to 1 hour
as ordered by physician
 Assessment
Subjective: Risk for Infection related
 “I’ve been to lochia discharge
breastfeeding Sara changing back to a
every 4 to 6 hours brownish color with foul
with no problems, odor
and she seems to be
fine.”
 “I’ve been so tired
for the past few
days, even though
I’m getting sleep,
but I haven’t been
hungry.”
 “My lower belly is
very sore. I also
noticed that my
vaginal discharge
has increased and
changed back to a
brownish color. It’s
smellier now, too.”
Objective:
 Small amount of
lochia, brownish
with a strong foul
odor, on pad
 Complains of pain
on palpation of
lower abdomen
 No bladder
distention
noted
 Uterine fundus
nonpalpable
Diagnosis Planning Interventions Rationale Evaluation
After 2 hours of nursing Independent: Alterations from normal After 4 hours of nursing
intervention the patient 1. Vital signs, lochia may be signs of intervention the patient
will experience lesser (character, amount, infection, retained was able to experience
pain and above a odor & presence of fragments or sub lesser pain and above a
tolerable level as clots), fundal height, & involution of the uterus. tolerable level as
manifested by: status of episiotomy manifested by:
were monitored.
 Verbalize  No redness or
understanding of risk 2. Proper perineal care Appropriate self care of anomalous
factors & hygiene were the perineum in discharge is present
 Identify intervention reinforced. postpartum patients at episiotomy line
and demonstrate reduces the risk of  Lochial discharge has
techniques to bacterial invasion. no foul odor
prevent risk of Antiseptic feminine  Temperature is not
infection. wash or clean warm greater than 38°C
water may be used.  Patient was able to
After 4 hours of nursing verbalize
intervention the patient 3. Emphasized early Mothers who had NSD understanding of
will experience lesser ambulation & beginning are allowed to ambulate how to do post-
pain and above a Postaprtal exercises 4 to 8 hrs after partum care for the
tolerable level as with resumption of childbirth. Circulation of perineal are
manifested by: normal activities as blood is promoted  Patient was able to
tolerated. through regular demonstrate
 Achieve timely movements thus it helps cleaning of the
wound healing in the healing process; perineal area
 Continue to be free prevents constipation,  Patient was able to
of any symptoms of circulatory problems & get enough sleep.
infection during urinary problems;
postpartum period promote rapid recovery; Therefore, the goals
hastens drainage of were met.
lochia; improves GI &
urinary function; &
provide a sense of well-
being.
4. Encouraged to eat Vitamin C is known to
foods that are rich in prevent infection; citrus
protein & vitamin C. fruits are rich in vitamin
C. Protein is needed for
  Lung sounds clear tissue repair &
 Urine clear regeneration; meat
 Urinalysis findings products, nuts &
normal legumes are rich sources
of which.
Vital Signs:
5. Enough rest & sleep This promotes healing
Temperature was also advised. by reducing basal
 100.9°F (oral) / metabolic rate &
38.2°C allowing oxygen &
Pulse nutrients to be utilized
 110 beats/min for tissue growth,
Respiratory Rate healing & regeneration.
 14 breaths/min
Blood Pressure Dependent:
 118/64 mmHg 1. Intake of antibacterial Antibiotics are used to
medications such as treat & prevent
amoxicillin & cephalexin infections caused by
as per doctor’s order & susceptible pathogens in
advise. skin structure infections.
 Assessment
Subjective: Risk for fluid volume
 “I’ve been deficit
breastfeeding Sara
every 4 to 6 hours
with no problems,
and she seems to be
fine.”
 “I’ve been so tired
for the past few
days, even though
I’m getting sleep,
but I haven’t been
hungry.”
 “My lower belly is
very sore. I also
noticed that my
vaginal discharge
has increased and
changed back to a
brownish color. It’s
smellier now, too.”
Objective:
 Small amount of
lochia, brownish
with a strong foul
odor, on pad
 Complains of pain
on palpation of
lower abdomen
 No bladder
distention
noted
 Uterine fundus
nonpalpable
Diagnosis Planning Interventions Rationale Evaluation
After 8 hours of nursing Independent: After 8 hours of nursing
intervention the patient 1. Review prenatal and Data helpful in intervention the patient
will experience lesser intrapartal/surgical evaluating current fluid was able to experience
pain and above a records for Hb level, status and replacement, lesser pain and above a
tolerable level as operative blood loss and presence of edema. tolerable level as
manifested by: fluid potential for manifested by:
diuresis.
 Maintain fluid  Fluid levels in the
volume at a 2. Monitor BP, pulse, Hypotension, body is adequate
functional level as status of mucous tachycardia, and dry and at a functioning
evidenced by membranes, capillary mouth may reflect level
individually refill; note presence of dehydration and  Stable vital signs
adequate urinary cyanosis. hypovolemia but may  Verbalized
output, stable vital not occur until understanding of the
signs. circulating blood volume importance of
has decreased by 30%– having adequate
50%, at which time signs fluids in the body
of peripheral
vasoconstriction may be Therefore, the goals
noted. were met.
3. Note character and Lochial flow should not
amount of lochial flow be heavy or contain
and consistency of clots; fundus should
fundus. Gently massage remain firmly
fundus as indicated. contracted at the
umbilicus. A boggy
uterus results in
increased flow and
blood loss. Note: As a
rule, lochial flow is
usually decreased by
second postoperative
day, thus “normal”
amount of flow
expected after vaginal
delivery would be
suspect for this client.
  Lung sounds clear 4. Monitor fluid intake Kidney function is a key
 Urine clear and urine output. Note index to circulating
 Urinalysis findings appearance, color, blood volume. As output
normal concentration, and decreases, specific
specific gravity of urine. gravity increases, and
Vital Signs: vice versa. Bloody urine
or urine containing clots
Temperature signifies possible
 100.9°F (oral) / bladder trauma
38.2°C associated with surgical
Pulse intervention.
 110 beats/min
Respiratory Rate 5. Encourage adequate Preferred route for
 14 breaths/min oral fluids (e.g., 6–8 replacement once
Blood Pressure glasses/day). nausea is
 118/64 mmHg resolved/peristalsis
returns. Adequate
intake allows for timely
removal of IV.

6. Provide information Maintaining adequate

in the importance of supply of fluids in our
having adequate fluids body helps our body
in the body. systems to function well
and to also avoid
dehydration.