Date

and Cues Need Nursing Diagnosis Objectives of Nursing Intervention Evaluation

Time Care

D Subjective: H Risk for infection That within my 1.) Assess temperature Dec. 16, 2010
E Patient was able to E related to lochia 2-hour span of and pulse. @
C. verbalize: A and episiotomy care my patient ® Increase in 9:00 a.m.
16, “Nanganak ko L will be able to temperature and
2 gahapon.” T ® Episiotomy is manifest maternal tachycardia “GOAL MET”
0 “Wala man pud ko H an intentional absence of may indicate infection.
1 gikalintura” incision into the infection 2.) Assess client’s After 2 hours span
0 P perineum through: perineum. of care, my patient:
@ Objective: E designed to a.) maintaining ® Assessing the client’s
7 am •Temperature R facilitate birth and temperature perineum will help a.) Was able to
was 36.9oC C avoid perineal within the identify the presence of maintain a
• Pulse rate E lacerations. normal range. infections. temperature
was 89 bpm. P Postpartal women b.) maintaining 3.) Encourage patient of 36.7

• Patient gave T are particularly pulse rate within to wash her hands which is

birth to a baby I prone to perineal the normal after handling pads within the

boy via O infection because range and use only her normal

Normal N lochia, furnishes a c.) the presence personal equipment. range.

Spontaneous - rich bed for of lochia rubra ® These actions b.) Was able to

Vaginal H bacterial growth. discharges but prevent the patient from maintain a

Delivery with E Because the without foul contracting or pulse rate of

Forceps A vagina lie in close odor. spreading infection. 92 which

Extraction L proximity to the d.) absence of 4.) Demonstrate the was within

• Has midline T rectum, there is abnormal proper way of the normal

Episiotomy H also always the discharges at handwashing. range.

• Has danger that episiotomy line ® Handwashing is the c.) Had