Name of Patient: Tui, Analyn Age: 29 Sex: Female Chief complaint: Uterine Contractions and discomfort

Physician: Dr. Ong AOG: 39 weeks Civil Status: Not specified

DATE AND NURSING GOALS & NURSING RATIONALE EVALUATION

September 5, Risk for After 8 hours of 1. The nurse will 1. Gestational After 8 hours of nursing care, the
2022 7:10 am infection nursing care, the Identify the risk diabetes, patient was able to:
related to patient will: factors of intrapartum ● The patient was notified
labor as ● The patient will infection. infections, PROM, and recognized the
Subjective: evidenced early recognize pre-eclampsia possible risk of infection.
The patient by second and be aware 2. Monitor and /eclampsia, and The patient verbalized
verbalized degree of the risk of report any signs prolonged labor “ay pwede diay ni ma
“naay nigawas laceration infection and symptoms increase the infection ang samad
murag tubig, ● The patient will of infections. incidence of saakong perineum nurse,
pero dili demonstrate 3. Administer infection. unsa may pwede nako
ko sigurado infection antibiotics as 2. Signs and buhaton ani?”
kung ihi ba to”. Scientific control to avoid ordered by the symptoms of ● The patient demonstrated
basis: infection in the physician. infection vary infection control to avoid
Susceptible perineal area. 4. Ensure proper according to the infection in the perineal
Objective: to invasion ● The patient will handling of body area area. The patient
● Vital and not develop an sterile involved. Assess changes her perineal pad
Signs: multiplicatio infection during instruments and for the following when bathroom use, she
n of the postpartum equipment in signs and sprays warm water on
*BP-90/60mm pathogenic period. terms of labor symptoms: such her perineal area every
Hg organisms, ● Alleviate or and perineal as redness, foul after voiding or
*HR-101 bpm which may reduce the flushing. smelling, pus defecating, she wears
*RR-17cpm compromise pain as well as 5. Demonstrate 3. Broad-spectrum loose cotton underwear,
*Temp-37.6’c health. the problems correct perineal antibiotics should and the patient
FHT-133-155b related with the cleaning after be administered demonstrated the correct
pm Reference: infection. voiding and until cultures or way of patting dry the
● Secon Herdman, H. defecation and pathogens are perineum which is from
d & Kamitsuru, frequent identified. Very ill front to back with the use
degree S. (2018). changing of patients or serious of toilet paper. The
lacerati Nanda peripads. infections require patient was aware of the
on International 6. Promote early IV antibiotics. intake of fiber in her diet
Nursing ambulation, Less severe to soften stool.
Diagnoses: balanced with infections can be ● The patient did not
Definitions adequate rest. treated outpatient develop infection during
and 7. Educate the with oral the postpartum period as
classification patient about the antibiotics. evidenced by normal
2018-2020 signs and 4. To help prevent vitals signs and the
(11th ed.). symptoms of infection, any absence of signs and
New York, infections. articles such as symptoms of infection.
NY: Thieme 8. Demonstrate gloves or ● The patient’s pain was
Publishers. wound care. instruments that lessened and the
are introduced into laceration was treated
the birth canal immediately. The patient
during labor, birth, verbalized “dili naman
and the kaayo sakit, makalakaw
postpartum period nasad ko hinay hinay.”
should be sterile.
In addition,
adherence to
standard infection GOAL MET
precautions is
essential. Gloves
should be worn
when contacting
blood, body fluid,
or other potentially
infectious
materials.
5. Changing pad
removes moist
medium that
favors bacterial
growth. Be certain
to instruct a
postpartal client in Student Nurse: Mary Alliza De
proper perineal Polonia
care, including
wiping from front
to back so that
she doesn’t bring
E. coli organisms
forward from the
rectum. When
giving perineal
care, the nurse
must wash hands
and wear gloves.
Each postpartal
client should have
their supplies and
should not share
them to prevent
the transfer of
pathogens from
one client to
another.
6. The nurse should
explore ways to
help the client get
enough rest. This
may increase
circulation,
promote clearing
respiratory
 secretions and
lochial drainage,
and enhance
healing and
general
well-being.
Ambulation and
limiting the time
the client remains
in obstetric
stirrups
encourages
circulation to the
lower extremities,
promotes venous
return, and
decreases clot
formation. Help
the client select
her activities to
exercise other
body parts or
stimulate her
mind.
7. Nurses should
educate patients
at discharge on
signs and
symptoms of
infection and
when to seek
prompt treatment
(fever, persistent
pain, changes in
lochia).
8. Teach the patient
to care for their
episiotomy
incision by not
bearing when
defecating (may
need to take stool
softeners), use ice
packs to decrease
the swelling, begin
warm sitz baths
24 hours after
birth, change
postpartum pads
every 2-4 hours,
and always wipe
front to back after
using the
bathroom and
clean the area by
spraying warm
water over the
area and patting
dry with a clean
towel. For a
C-section incision,
keep the dressing
clean and dry until
instructed to
remove. Wash
with soap and
water as
instructed and do
not scrub.