Careplan

Student Name: Neal Patel Date of care:10/5/10

Assessment Nursing Diagnosis Expected Outcomes

Maternal info:
RM: LDR 6 Risk for infection related to perineal Goal: Patient will not exhibit any signs and
Age: 30 Admit Ht: 5’5” Wt: 174 lb trauma due to laceration symptoms of infection during 12 hour shift.
Ethnicity: White
Primiary Language: English
Occupation: homemaker
Family Comp: Husband
Antepartal Info: OB Care: yes LMP: 12/10/09
EDC: 10/2/10 G: 2 P:2 AB: 0
Blood type: 0 RH: + Rubella: + RPR: -
HIV: non-reactive
Allergies: cephalexin monohydrate
IV: Lactated ringers IV premix Rate: 125ml/hr I-
1000ml
Medication: Nubain 10mg IV q3hr PRn
Diet: regular diet
Activity: Ambulatory
Delivery Date/Time: 10/4/10 1027 (vaginal birth)
Anesthesia: local
Breasts: Soft Nipples: Everted
Bowels: Active
Bladder: Voiding Color: Yellow
Episiotomy: none Laceration: lst degree
REEDA: none Edema: none
Reflexes: normal
Emotional Support: family
Vital signs:
Maternal:
1050: BP: 134/75 T: 97.5 HR: 81 RR: 18
1130 : BP: 126/58 T: 98.6 HR: 77 RR: 20
1250: BP: 126/80 T: 97.9 HR: 87 RR: 20
Infant: 1045: T: 97.5 HR: 132 RR: 36
Nursing Interventions
1. Assess the perineal frequently for infection
2. Report laboratory values such as WBC
3. Monitor patient’s vital signs. (Possible Clue for
infection)
4. Give stool softener
5. Patient performs aseptic technique when
performing perineal care
6. Use hand hygiene
7. Teach patient to wash and pat dry perineal area.
8. Report any signs of infection such as redness,
warmth, increase temp, discharge
Rationale Evaluation
1. Detecting signs and of infection early
can help decrease further complications. Patient was free from infection and displayed
2. WBC and automated absolute no sypmtoms
neutrophil count are diagnostic test to see
if patient has an infection.
3. To ensure patient doesn’t have an
increase of temp (fever), decreased BP,
steady pulse.
4. Urinating or having a bowel movement
is painful, so using a stool softener can
help decrease pain to perineal area.
5. Hygiene care is important to prevent
infection in at risk client.
6. Hand Hygiene is very important to
prevent infection.
7. To see if patient have any signs of
infection such as pus leaking from
laceration or foul smelling discharge.
8. Washing reduces pain to laceration, and
patting the area dry helps reduce the
growth of bacteria.
 Nursing Diagnosis
Acute Pain related to effects of uterine
contractions exhibited by patient
screaming and requesting pain meds.
Expected Outcomes
Goal: Patient will report any
pain as soon as possible and
will reduce pain to tolerable
level during 12 hour shift

Nursing Interventions Rationale Evaluation

1.Establish a comfort function goal with the pt.
2. Use nonpharmacological methods to help control pain, such as
imagery, relaxation, listening to music, breathing techniques,
Gate control
3. Administer PRN pain medication
5. Ask the client to explain past pregnancies with pain and the
methods used to manage pain previously
6. Describe the adverse effects of unrelieved pain.
4. Asses and describe patients pain in depth regularly
7. Establish and adhere to birth plan with patient (environment-
lighting, noise, temperature).
8.Teach patient different position
1. The pain rating that allows the client to
have comfort and appropriate function Although patient was able to
should be determined because this allows alieve the pain somewhat, it
a way to measure outcomes of pain was not tolerable.
management.
2. Opioid analgesics are for the treatment
of mild severe pain.
3. see if the PRN medication (Nubain)
was effective at reducing her pain.
5. The nurse can use the same method
that the patient used for pain she
experienced (with 1st child) in the past to
help with the pain she has now.
6. Nurse can note down what symptoms
the patient gets when pain is not relieved.
7. Birth plan is adjusted to patient’s
preferences during birth.
8. Changing positions can help relieve
patients pain.