NURSING CARE PLAN ASSESSMENT SUBJECTIVE: No Verbalization OBJECTIVE: • Presence of perineal wounds due to episiotomy second degree • Not

practicing frequent changing of pads DIAGNOSIS SCIENTIFIC EXPLANATION Risk for infection Contamination of a related to presence of wound surface with surgical wounds as microorganism thus evidenced by MER these colonization 2nd degree has a complete new cells for oxygen and nutrition and because their by-products can interfere with a healthy surface condition that leads to infection -Fundamentals of Nursing by Kozier page 910 PLANNING Long Term: After two days of interventions the client will be able to free from infection. Short Term: After two hours of interventions the client will be able to: • Verbalize Health Teachings • Demonstrate at least 3 ways on how to prevent infection. INTERVENTION Independent: • Change perineal pads frequently. RATIONALE • To prevent vaginal contamination or infection. • To promote cleanliness to the perineal area • To avoid edema EVALUATION Long Term: After two days of interventions the client was able to free from infection. Short Term: After two hours of interventions the client was able to: • Verbalize Health Teachings • Demonstrate at least 3 ways on how to prevent infection.

• Perform perineal care • Warm compressed may be applied to the genital area Collaborative: • Sitz bath may be ordered

• To aid healing of the perineum thorough application of moist heat

LIST OF PRIORIIZED PROBLEM Nursing Diagnosis Pain related to damage on muscle tissue as evidenced by episiotomy MER 2nd degree Rank Justification It is highly prioritized because based on the Maslow’s Hierarchy of Needs the physiologic needs of the patient is greatly affected and need an immediate action.

1

Constipation related to irregular defecation as evidenced by not defecating for 4-5 days.

2

It is second prioritized problem because based on the Maslow’s Hierarchy of Needs the physiologic needs of the patient is affected and need an immediate action.

Risk for infection related to presence of surgical wounds as evidenced by MER 2nd degree.

3

It is third prioritized because based on the Types of Nursing Diagnosis the patient’s health is at “risk” and may likely happen.

Risk for falls related to absence of side rails secondary to not being raised.

4

It is fourth prioritized because based on the Types of Nursing Diagnosis the patient’s health is at “risk” and may likely happen.

Health seeking behavior related to precipitating concern about the current health status as evidenced by hospitalization

5

It is least prioritized because based on the Types of Nursing Diagnosis the patient’s health is at wellness state

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