Name: Arpon, Mary Doind Llyra__________________ Section_A_ Date:_03.20.

20_______________
Case:_G1P1 NSD c episiotomy _________________________________________________________________________
Problem # 1:_Lack of knowledge_________________________________________________________________________________
Nursing Diagnosis: 4th day Post-NSD; ineffective breastfeeding, secondary to knowledge deficit______________ _________________
Rationale:_First time mothers may have anxiety around breastfeeding that is contributing to their difficulties due to limited_______
experience. Knowledge and skill in providing infant care after giving birth. _______________________________________________
Reference:_NursingCrib.com____________________________________________________________________________________
Objective Cues: Nursing Intervention: Rationale Evaluation
Presence of: Independent Goal met
>active questions >Provided health teachings about The mother was able
regarding breastfeeding: to gain knowledge
breastfeeding.  Proper positioning >For effective breastfeeding about the proper way
>facial expression  Breastfeed every 2-3 hrs, 8-10 >Soap will remove the natural oils to hold her baby,
suggesting fear times daily. that are present on your breast and breastfeed her baby
>G1P1 NSD  How to get god attachment nipples and contribute to drying and and clean her breasts
(make sure baby sucks the cracking. by verbalizing it.
Subjective Cues: areola, not just the nipple, >To be able to breastfeed properly
“Unang baby ko kase to. Babys top and bottom lip and for the safety of the baby.
Di ko alam gagawin ko. should be turned out. Baby’s
Nakakapag pasuso chin should be pressed into
naman ako kaso di ko the breast”
alam ang tamang > Taught pt. to clean breast with only
paraan” as the mother water and cotton, don’t use soap and
verbalized. lotion.
> Instructed pt. to support baby’s
head neck and back. >For lactation
 Dependent:
>Nutralac (1 capsule)

Problem # 2: Fear_____________________________________________________
Nursing Diagnosis: Anxiety related to threat to/or change in health status________________________________________________
Rationale: Uneasy feeling of discomfort or dread accompanied by automatic response; source is often unspecific or unknown to the
individual; a .feeling of apprehension caused by anticipation anticipation of danger. It is an altering signal that warns impending
danger and enables the individual to take measure to deal with the threat._______________________________________________
Reference:_NANDA pg. 70 ______________________________________________________________________________________

Objective Cues: Nursing Intervention: Rationale Evaluation

>Restlessness Independent
>Difficulty of sleeping >Monitored Vital signs (irregular >to identify physical responses Goal met.
pulse and rapid breathing) associated with both medical and The pt. appeared
emotional conditions. relaxed and
Subjective Cues: >Used presence, touch, verbalization manageable.
“Unang anak ko kase or demeanour to remind client and to >Being supportive and approachable
to.Di ko alam kung encourage expressions or clarification encourages communication.
makakapagtrabaho of needs, concerns, questions.
kaagad ako pagkatapos
ko dito” as verbalized >Explained everything necessary >To educate the patient regarding the
by the pt. regarding the concern. concern to reduce anxiety.

>Approached pt. in a soft way, do not >Patient will not be threatened and
confront, argue and debate. may feel safe enough to look at the
 behavior.
>To avoid increased level of anxiety

>Explained whatever given

medication to the pt.

Risk # 1:_Infection_____________________________________________________________________________________________
Nursing Diagnosis:_Risk for uterine infection related to lochia and episiotomy_____________________________________________
Rationale:_Due to the episiotomy there is an increased risk for being invaded by pathogenic organisms. Laceration and broken skin_
destroys the body’s first line of defense, the skin.____________________________________________________________________
Reference:_NursingCrib.com____________________________________________________________________________________

Objective Cues: Nursing Intervention: Rationale Evaluation

>with firm and Independent
contracted uterus >Assesed VS, Lochia (character, >alterations from normal may be Goal met.
>NSD with episiotomy amount, odor, and presence of clots), signs of infection, retained fragments No redness or
>used single pad for 12 fundal ht., and status of episiotomy or sub involution of the uterus. anomalous discharge
hrs. monitored is present at
> T= 37.6 >appropriate self-care of the episiotomy line;
>Taught pt. proper perineal care and perineum reduces the risk of bacterial lochial discharge has
hygiene. invasion. Antiseptic feminine wash or no foul odor;
clean warm water may be used. temperature is not
>Emphasized early ambulation and greater than 40C.
beginning postpartum exercises with >Mothers who had NSD can ambulate
resumption of normal activities as 4-8 hrs. after childbirth. Circulation of
Subjective Cues: tolerated. blood is promoted through regular
>Minimal lochial movements thus helps in the healing
discharge verbalized process, prevents constipation,
circulatory problems and urinary
problems, promote rapid recovery;
hastens drainage of lochia; improves
GI and urinary function; and provide a
sense of wellbeing.