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06-CarePlan-OB-CarePlan

06-CarePlan-OB-CarePlan

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Published by Dolce Ibarra

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Published by: Dolce Ibarra on Feb 03, 2011
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Care Plans
Printed: 02/02/2011 20:08Student:
Ibarra, Dolce
Patient:
x x (Pt # 18363)
 
Clinical Date: 2011-02-02
Nursing Diagnosis: Pain, Acute
Related To:
ADDED-Involution| ADDED-Episiotomy repair
Evidenced By:
ADDED-Uterine cramping| ADDED-Sutures at perineum| ADDED-Patient report of pain level 2/10 at perineumand abdomen
Goals:
ADDED-Maintain pain level at 0-3/10 within one hour of interventions| ADDED-Vital signs within normal limits| ADDED-Nosign of inflammation at suture site
Interventions:
ADDED-Assess & document pain characteristics: quality, severity, & location. /R/Assessment of pain is first stepin successful pain management (Taylor, 2008) | ADDED-Provide perineal ice pack. /R/ Ice promotes vasoconstriction and reducesedema which will reduce discomfort. (Klossner/Hatfiend, 2006)| ADDED-Give Ibuprofen as ordered, evaluating effectiveness andobserving for any signs and symptoms of adverse effects. /R/ Mild to moderate pain is well managed with analgesics (Deglin, 2008)| ADDED-Teach patient how and when to ask for pain medicine /R/ Patients may feel aprehensive about asking for medications ifnot specifically instructed that it is okay to do so. (Taylor, 2008)| 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)| ADDED-Teach non-pharmacological methods for controlling involutions discomfort such as: warm compress, positioning for comfort, adequate rest andnutrition, and early ambulation. (Klossner/Hatfield, 2006) | ADDED-Teach about sitz baths and local anesthetics such as witchhazel pads and benzocaine to treat perineal pain after discharge. (Klossner/Hatfield, 2006)
Rationale for Interventions:
.
Intervention Evaluations:
Intervention: ADDED-Assess & document pain characteristics: quality, severity, & location. /R/Assessmentof pain is first step in successful pain management (Taylor, 2008)Status: EffectiveComment: Patient reports pain 2/10 at adbomen and perineum.Intervention: ADDED-Provide perineal ice pack. /R/ Ice promotes vasoconstriction and reduces edemawhich will reduce discomfort. (Klossner/Hatfiend, 2006)Status: EffectiveComment: Perineal ice pack not available, provided clean washclothes and pitcher of ice water for soakingand applying to perineal area.Intervention: ADDED-Give Ibuprofen as ordered, evaluating effectiveness and observing for any signs andsymptoms of adverse effects. /R/ Mild to moderate pain is well managed with analgesics (Deglin, 2008)Status: EffectiveComment: 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 feelaprehensive about asking for medications if not specifically instructed that it is okay to do so. (Taylor, 2008)Status: EffectiveComment: Patient requested pain medication before pain increased in severity.Intervention: ADDED-Explain postpartum recovery process and s/s to report. /R/ Realistic expectations mayrelieve anxiety and thereby reduce the sensation of pain. (Klossner/Hatfield, 2006)Status: EffectiveComment: Patient verbalized understanding of timeframe for healing of episiotomy site and completion ofinvolution.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: EffectiveComment: 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 andbenzocaine to treat perineal pain after discharge. (Klossner/Hatfield, 2006)Status: EffectiveComment: Patient verbalized understanding of home remedies for perineal pain treatment and stated shewould try these interventions at home.
 
Care Plans
Printed: 02/02/2011 20:08Student:
Ibarra, Dolce
Patient:
x x (Pt # 18363)
Goal Evaluations:
Goal: ADDED-Maintain pain level at 0-3/10 within one hour of interventionsStatus: ReachedComment: Pain reported as 2/10 for duration of shiftGoal: ADDED-No sign of inflammation at suture siteStatus: ReachedComment: S/S of inflmation did not increase during shift
Nursing Diagnosis: Infection
Related To:
Invasive procedures| ADDED-Laceration at perineum (grade 2 episiotomy)| ADDED-Tissue impairment d/t vaginaldelivery
Evidenced By:
Presence of favorable condition for infection| ADDED-Sutured wound at perineum| ADDED-Tissue damage d/tvaginal delivery| ADDED-Pain and tenderness at perineum| ADDED-Low baseline lymphocyte count
Goals:
Patient will remain infection free| Patient will be able to identify signs/symptoms of infection | ADDED-Patient will be ableto demonstrate understanding of proper hygiene and technique for peri-care.
Interventions:
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) | 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 and subside are indicative of infection. (Klossner/Hatfield, 2008)|ADDED-Wash hands/wear gloves and teach other caregivers to wash hands/wear gloves before contact with patient and betweenprocedures with patient. /R/ Friction and running water effectively remove microorganisms from hands. Washing betweenprocedures reduces the risk of transmitting pathogens from one area of the body to another. (Taylor, 2006)| ADDED-Encourageintake of protein-rich foods and fluid intake of 2000 ml to 3000 ml of water per day. /R/ Maintains optimal nutritional status. (Taylor,2008)| ADDED-Administer analgesics as ordered. /R/ Control of pain facilitates easier wound care and peri-care postpartum.(Klossner/Hatfield, 2006)| ADDED-Teach patient or caregiver to wash hands often, especially after toileting, before meals, andbefore and after administering self-care. /R/ Patients and caregivers can spread infection from one part of the body to another, aswell as pick up surface pathogens; hand washing reduces these risks. (Taylor, 2008)| ADDED-Teach patient and caregiver thesigns and symptoms of infection, and when to report these to the physician or nurse. (Taylor, 2008)
Rationale for Interventions:
.
Intervention Evaluations:
Intervention: ADDED-Assess for signs of infection: Redness, swelling, increased pain, or purulent drainageat incision. /R/ Identifying s/s of infection allows for prompt intervention. (Taylor, 2008)Status: EffectiveComment: No s/s of infection were noted prior to end of shift.Intervention: ADDED-Assess for elevated tempurature, tachycardia, increased respirations. /R/ Fever of upto 100.4°F for 48 hours after surgery is related to the stress of delivery; after 48 hours, fever above 99.8°Fsuggests infection; fever spikes that occurStatus: EffectiveComment: Tempurature remained well below 100.4°F during shift.Intervention: ADDED-Wash hands/wear gloves and teach other caregivers to wash hands/wear glovesbefore contact with patient and between procedures with patient. /R/ Friction and running water effectivelyremove microorganisms from hands. Washing between procedureStatus: EffectiveComment: 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 waterper day. /R/ Maintains optimal nutritional status. (Taylor, 2008)Status: EffectiveComment: Patient consummed 95% of meals served.Intervention: ADDED-Administer analgesics as ordered. /R/ Control of pain facilitates easier wound careand peri-care postpartum. (Klossner/Hatfield, 2006)Status: EffectiveComment: Patient verbalized understanding of the rationale for using hand hygiene.Intervention: ADDED-Teach patient or caregiver to wash hands often, especially after toileting, beforemeals, and before and after administering self-care. /R/ Patients and caregivers can spread infection fromone part of the body to another, as well as pick up s
 
Care Plans
Printed: 02/02/2011 20:08Student:
Ibarra, Dolce
Patient:
x x (Pt # 18363)
Status: EffectiveComment: 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 reportthese to the physician or nurse. (Taylor, 2008)Status: EffectiveComment: Early detection of infection and early intervention produces the best outcomes.
Goal Evaluations:
Goal: Patient will remain infection freeStatus: ReachedComment: S/S of infection remained absent for duration of shift.Goal: Patient will be able to identify signs/symptoms of infectionStatus: ReachedComment: Patient states "Call doctor if I see swelling, drainage, increased redness, or develop a fever over100.4degrees".Goal: ADDED-Patient will be able to demonstrate understanding of proper hygiene and technique for peri-care.Status: ReachedComment: Patient verbalized understanding of steps for proper peri-care.
Nursing Diagnosis: Ineffective thermoregulation
Related To:
ADDED-Immature heat-regulating mechanisms
Evidenced By:
ADDED-Birth within past 48 hours| ADDED-minimal subcutaneous tissue
Goals:
ADDED-Keep baby's tempurature between 97.7 and 99.5 degrees
Interventions:
ADDED-Assess tempurature, apical pulse, and respiration rate every 4 hours. /R/ Monitoring tempurature allowsfor prompt intervention if tempurature is outside of beneficial range. (Klossner/Hatfield, 2006)| ADDED-Swaddle baby and keep capon head. /R/ Swaddling and capping helps to prevent heat loss. (Klossner/Hatfield, 2006)| ADDED-Encourage "kangaroo care" withmom and dad. /R/ Skin-to-skin contact is an excellent way to keep baby warm and provide family-centered care. (Klossner/Hatfield,2006)| ADDED-Teach mom and dad about thermoregulation. Suggest ways to prevent uneccessary heat loss at home such asavoiding drafty locations and avoiding placing baby on cold surface. (Klossner/Hatfield, 2006)| ADDED-Teach mom and dad to notoverheat baby by covering or wrapping too much. /R/ Warm baby is good, hot baby (hyperthermia) is not good and can be asharmful as hypothermia. (Klossner/Hatfield, 2006)
Rationale for Interventions:
.
Intervention Evaluations:
Intervention: ADDED-Assess tempurature, apical pulse, and respiration rate every 4 hours. /R/ Monitoringtempurature allows for prompt intervention if tempurature is outside of beneficial range. (Klossner/Hatfield,2006)Status: EffectiveComment: 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 heatloss. (Klossner/Hatfield, 2006)Status: EffectiveComment: 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 anexcellent way to keep baby warm and provide family-centered care. (Klossner/Hatfield, 2006)Status: EffectiveComment: 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 uneccessaryheat loss at home such as avoiding drafty locations and avoiding placing baby on cold surface.(Klossner/Hatfield, 2006)Status: EffectiveComment: Mom was receptive to information and stated she understood the importance of keeping babywarm.

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