Name of Patient: October 1-15, 2012


ASSESSMENT Subjective: “ Masakit ang pag-hi ko” as verbalized by the patient. Objective:  Blood stained urine noted  With presence of pus cells 0-2 as a result in urinalysis  With foul odor, whitish vaginal discharge noted  vital signs as follows: T= 37.9oC PR= 85 bpm RR= 22 bpm BP= 120/90 mmHg

NURSING DIAGNOSIS Infection related to altered physiologic infection barrier of the vaginal environment secondary to persistent uterine bleeding as evidenced by blood stained urine

INFERENCE Unkown etiology Stimulation of increase estrogen production Proliferation of cells in the uterus Overgrowth of the endometrial lining Develops in the uterine fibroid Interference in the vascular supply Deterioration in the interior part of the fibroid

PLANNING After 3 days of nursing intervention, the patient will be free from infection.

INTERVENTION Independent: 1. Encourage oral fluid intake of fruit juices, especially coconut juice. 2. Increase oral fluid intake of 1-2 liters a day to promote urination. 3. Encouraged perineal care once a day to maintain acidity of the vagina

RATIONALE  Acid ash juices have pH acidifier retarding bacterial growth.  Frequent urination prevents urine retention that could cause bacterial growth.  Reduce risk of contamination or ascending infection.

EVALUATION After 3 days of nursing intervention, goal was partially met as evidenced by pus cells in the urine and evident blood-stained urine still noted.

Goal met.odor and presence of clots. No redness or anomalous discharge is . INFERENCE Due to episiotomy there is an increased risk for being invaded by PLANNING Short Term Goal: After 8 hours of nursing intervention. lochia character. Vital signs. amount. NURSING DIAGNOSI S Risk for uterine infection related to lochia and episiotomy.Name of Patient: October 16-31. the NURSING CARE PLAN FOR NORMAL SPONTANEOUS DELIVERY INTERVENTION INDEPENDENT 1. fundal height and RATIONALE EVALUATION  Alteration from normal maybe signs of infection. retained fragments or sub involution of the uterus.” as claimed by the patient. 2012 ASSESSMEN T Subjective: “ May konti pa akong pagdurugo.

present at episiotomy line. 5. 3.  Antibiotics are used to treat & prevent infections caused by susceptible pathogens in skin structure infections. Lacerations and broken skin destroys the body’s first line of defense.  Mothers who had NSD are allowed to ambulate 4-8 hours after childbirth. Enough rest and sleep was also advised. meat products. .Objective:  Minimal vaginal bleeding noted  With firm and contracte d uterus noted upon palpation  S/P NSD with episiotom y  Vital signs as follows: T= 37oC PR= 81 bpm RR= 20 bpm BP= 110/80 mmHg pathogenic organisms. promote rapid recovery. Administer antibiotic as ordered. & provide a sense of well-being.  Appropriate self care of the perineum in postpartum patient reduces the risk of bacterial invasion. nuts & legumes are rich sources of which. Encouraged to eat foods that are rich in protein and vitamin C. 4. 2.  This promotes healing by reducing basal metabolic rate & allowing oxygen & nutrients to be utilized for tissue growth. citrus fruits are rich in vitamin C. Proper perineal care and hygiene were emphasized. improves GI & urinary function. lochial discharge has no foul odor. Long Term Goal: After 3 days of nursing intervention. Emphasized early ambulation and beginning postpartal exercises with resumption of normal activities as tolerated. Protein is needed for tissue repair & regeneration. prevents constipation circulatory problems & urinary problems. the patient will achieve timely wound healing and will continue to be free from any symptoms of infection during postpartum period.  Vitamin C is known to prevent infection. DEPENDENT 6. Circulation of blood is promoted through regular movement thus it helps in the healing process. Antiseptic feminine wash or clean warm water may be used. temperature is not greater than 40°C. patient will verbalize understanding of risk factors and will identify intervention and demonstrate techniques to prevent risk of infection. healing & regeneration. hastens drainage of lochia. the skin. status of episiotomy were monitored.

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