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Care Plans
Student: Ibarra, Dolce Patient: x x (Pt # 18363)
Intervention Evaluations:
Intervention: ADDED-Assess & document pain characteristics: quality, severity, & location. /R/Assessment
of pain is first step in successful pain management (Taylor, 2008)
Status: Effective
Comment: Patient reports pain 2/10 at adbomen and perineum.
Intervention: ADDED-Provide perineal ice pack. /R/ Ice promotes vasoconstriction and reduces edema
which will reduce discomfort. (Klossner/Hatfiend, 2006)
Status: Effective
Comment: Perineal ice pack not available, provided clean washclothes and pitcher of ice water for soaking
and applying to perineal area.
Intervention: ADDED-Give Ibuprofen as ordered, evaluating effectiveness and observing for any signs and
symptoms of adverse effects. /R/ Mild to moderate pain is well managed with analgesics (Deglin, 2008)
Status: Effective
Comment: Medication was administered as ordered. Pain level did not increase.
Intervention: ADDED-Teach patient how and when to ask for pain medicine /R/ Patients may feel
aprehensive about asking for medications if not specifically instructed that it is okay to do so. (Taylor, 2008)
Status: Effective
Comment: Patient requested pain medication before pain increased in severity.
Intervention: ADDED-Explain postpartum recovery process and s/s to report. /R/ Realistic expectations may
relieve anxiety and thereby reduce the sensation of pain. (Klossner/Hatfield, 2006)
Status: Effective
Comment: Patient verbalized understanding of timeframe for healing of episiotomy site and completion of
involution.
Intervention: ADDED-Teach non-pharmacological methods for controlling involutions discomfort such as:
warm compress, positioning for comfort, adequate rest and nutrition, and early ambulation.
(Klossner/Hatfield, 2006)
Status: Effective
Comment: Patient was able to use pillows to make position during breastfeeding to increase comfort.
Intervention: ADDED-Teach about sitz baths and local anesthetics such as witch hazel pads and
benzocaine to treat perineal pain after discharge. (Klossner/Hatfield, 2006)
Status: Effective
Comment: Patient verbalized understanding of home remedies for perineal pain treatment and stated she
would try these interventions at home.
Printed: 02/02/2011 20:08
Care Plans
Student: Ibarra, Dolce Patient: x x (Pt # 18363)
Goal Evaluations:
Goal: ADDED-Maintain pain level at 0-3/10 within one hour of interventions
Status: Reached
Comment: Pain reported as 2/10 for duration of shift
Intervention Evaluations:
Intervention: ADDED-Assess for signs of infection: Redness, swelling, increased pain, or purulent drainage
at incision. /R/ Identifying s/s of infection allows for prompt intervention. (Taylor, 2008)
Status: Effective
Comment: No s/s of infection were noted prior to end of shift.
Intervention: ADDED-Assess for elevated tempurature, tachycardia, increased respirations. /R/ Fever of up
to 100.4° F for 48 hours after surgery is related to the stress of delivery; after 48 hours, fever above 99.8° F
suggests infection; fever spikes that occur
Status: Effective
Comment: Tempurature remained well below 100.4° F during shift.
Intervention: ADDED-Wash hands/wear gloves and teach other caregivers to wash hands/wear gloves
before contact with patient and between procedures with patient. /R/ Friction and running water effectively
remove microorganisms from hands. Washing between procedure
Status: Effective
Comment: Standard precautions were used at every encounter with patient or baby.
Intervention: ADDED-Encourage intake of protein-rich foods and fluid intake of 2000 ml to 3000 ml of water
per day. /R/ Maintains optimal nutritional status. (Taylor, 2008)
Status: Effective
Comment: Patient consummed 95% of meals served.
Intervention: ADDED-Administer analgesics as ordered. /R/ Control of pain facilitates easier wound care
and peri-care postpartum. (Klossner/Hatfield, 2006)
Status: Effective
Comment: Patient verbalized understanding of the rationale for using hand hygiene.
Intervention: ADDED-Teach patient or caregiver to wash hands often, especially after toileting, before
meals, and before and after administering self-care. /R/ Patients and caregivers can spread infection from
one part of the body to another, as well as pick up s
Printed: 02/02/2011 20:08
Care Plans
Student: Ibarra, Dolce Patient: x x (Pt # 18363)
Status: Effective
Comment: Early detection of infection and early intervention produces the best outcomes.
Intervention: ADDED-Teach patient and caregiver the signs and symptoms of infection, and when to report
these to the physician or nurse. (Taylor, 2008)
Status: Effective
Comment: Early detection of infection and early intervention produces the best outcomes.
Goal Evaluations:
Goal: Patient will remain infection free
Status: Reached
Comment: S/S of infection remained absent for duration of shift.
Goal: ADDED-Patient will be able to demonstrate understanding of proper hygiene and technique for peri-
care.
Status: Reached
Comment: Patient verbalized understanding of steps for proper peri-care.
Intervention Evaluations:
Intervention: ADDED-Assess tempurature, apical pulse, and respiration rate every 4 hours. /R/ Monitoring
tempurature allows for prompt intervention if tempurature is outside of beneficial range. (Klossner/Hatfield,
2006)
Status: Effective
Comment: Vital signs were monitored and found to be within normal limits.
Intervention: ADDED-Swaddle baby and keep cap on head. /R/ Swaddling and capping helps to prevent heat
loss. (Klossner/Hatfield, 2006)
Status: Effective
Comment: Mom kept baby swaddled except for when skin-to-skin.
Intervention: ADDED-Encourage "kangaroo care" with mom and dad. /R/ Skin-to-skin contact is an
excellent way to keep baby warm and provide family-centered care. (Klossner/Hatfield, 2006)
Status: Effective
Comment: Mom verbalized understanding of benefits of skin-to-skin contact and practiced it.
Intervention: ADDED-Teach mom and dad about thermoregulation. Suggest ways to prevent uneccessary
heat loss at home such as avoiding drafty locations and avoiding placing baby on cold surface.
(Klossner/Hatfield, 2006)
Status: Effective
Comment: Mom was receptive to information and stated she understood the importance of keeping baby
warm.
Printed: 02/02/2011 20:08
Care Plans
Student: Ibarra, Dolce Patient: x x (Pt # 18363)
Intervention: ADDED-Teach mom and dad to not overheat baby by covering or wrapping too much. /R/
Warm baby is good, hot baby (hyperthermia) is not good and can be as harmful as hypothermia.
(Klossner/Hatfield, 2006)
Status: Effective
Comment:
Goal Evaluations:
Goal: ADDED-Keep baby's tempurature between 97.7 and 99.5 degrees
Status: Reached
Comment: Goal met: Baby's tempurature stayed within safe range.