Printed: 02/02/2011 20:08

Care Plans
Student:

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 perineum
and abdomen Goals: ADDED-Maintain pain level at 0-3/10 within one hour of interventions| ADDED-Vital signs within normal limits| ADDED-No sign of inflammation at suture site Interventions: ADDED-Assess & document pain characteristics: quality, severity, & location. /R/Assessment of pain is first step in successful pain management (Taylor, 2008) | ADDED-Provide perineal ice pack. /R/ Ice promotes vasoconstriction and reduces edema which will reduce discomfort. (Klossner/Hatfiend, 2006)| ADDED-Give Ibuprofen as ordered, evaluating effectiveness and observing 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 if not 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 nonpharmacological methods for controlling involutions discomfort such as: warm compress, positioning for comfort, adequate rest and nutrition, and early ambulation. (Klossner/Hatfield, 2006) | ADDED-Teach about sitz baths and local anesthetics such as witch hazel 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/Assessment of pain is first step in successful pain management (Taylor, 2008) Status: Effective Comment: Patient reports pain 2/10 at adbomen and perineum. Intervention: ADDED-Provide perineal ice pack. /R/ Ice promotes vasoconstriction and reduces edema which will reduce discomfort. (Klossner/Hatfiend, 2006) Status: Effective Comment: Perineal ice pack not available, provided clean washclothes and pitcher of ice water for soaking and applying to perineal area. Intervention: ADDED-Give Ibuprofen as ordered, evaluating effectiveness and observing for any signs and symptoms of adverse effects. /R/ Mild to moderate pain is well managed with analgesics (Deglin, 2008) Status: Effective Comment: 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 feel aprehensive about asking for medications if not specifically instructed that it is okay to do so. (Taylor, 2008) Status: Effective Comment: Patient requested pain medication before pain increased in severity. Intervention: 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) Status: Effective Comment: Patient verbalized understanding of timeframe for healing of episiotomy site and completion of involution. 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: Effective Comment: 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 and benzocaine to treat perineal pain after discharge. (Klossner/Hatfield, 2006) Status: Effective Comment: Patient verbalized understanding of home remedies for perineal pain treatment and stated she would try these interventions at home.

Printed: 02/02/2011 20:08

Care Plans
Student:

Ibarra, Dolce

Patient:

x x (Pt # 18363)

Goal Evaluations:
Goal: ADDED-Maintain pain level at 0-3/10 within one hour of interventions Status: Reached Comment: Pain reported as 2/10 for duration of shift Goal: ADDED-No sign of inflammation at suture site Status: Reached Comment: 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 vaginal
delivery

Evidenced By: Presence of favorable condition for infection| ADDED-Sutured wound at perineum| ADDED-Tissue damage d/t vaginal 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 able to 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 between procedures with patient. /R/ Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another. (Taylor, 2006)| ADDED-Encourage intake 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, and before and after administering self-care. /R/ Patients and caregivers can spread infection from one part of the body to another, as well as pick up surface pathogens; hand washing reduces these risks. (Taylor, 2008)| ADDED-Teach patient and caregiver the signs 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 drainage at incision. /R/ Identifying s/s of infection allows for prompt intervention. (Taylor, 2008) Status: Effective Comment: No s/s of infection were noted prior to end of shift. Intervention: 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 Status: Effective Comment: Tempurature remained well below 100.4° F during shift. Intervention: ADDED-Wash hands/wear gloves and teach other caregivers to wash hands/wear gloves before contact with patient and between procedures with patient. /R/ Friction and running water effectively remove microorganisms from hands. Washing between procedure Status: Effective Comment: 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 water per day. /R/ Maintains optimal nutritional status. (Taylor, 2008) Status: Effective Comment: Patient consummed 95% of meals served. Intervention: ADDED-Administer analgesics as ordered. /R/ Control of pain facilitates easier wound care and peri-care postpartum. (Klossner/Hatfield, 2006) Status: Effective Comment: Patient verbalized understanding of the rationale for using hand hygiene. Intervention: ADDED-Teach patient or caregiver to wash hands often, especially after toileting, before meals, and before and after administering self-care. /R/ Patients and caregivers can spread infection from one part of the body to another, as well as pick up s

Printed: 02/02/2011 20:08

Care Plans
Student:

Ibarra, Dolce

Patient:

x x (Pt # 18363)

Status: Effective Comment: 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 report these to the physician or nurse. (Taylor, 2008) Status: Effective Comment: Early detection of infection and early intervention produces the best outcomes.

Goal Evaluations:
Goal: Patient will remain infection free Status: Reached Comment: S/S of infection remained absent for duration of shift. Goal: Patient will be able to identify signs/symptoms of infection Status: Reached Comment: Patient states "Call doctor if I see swelling, drainage, increased redness, or develop a fever over 100.4degrees". Goal: ADDED-Patient will be able to demonstrate understanding of proper hygiene and technique for pericare. Status: Reached Comment: 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 allows
for prompt intervention if tempurature is outside of beneficial range. (Klossner/Hatfield, 2006)| ADDED-Swaddle baby and keep cap on head. /R/ Swaddling and capping helps to prevent heat loss. (Klossner/Hatfield, 2006)| ADDED-Encourage "kangaroo care" with mom 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 as avoiding drafty locations and avoiding placing baby on cold surface. (Klossner/Hatfield, 2006)| ADDED-Teach mom and dad to not overheat baby by covering or wrapping too much. /R/ Warm baby is good, hot baby (hyperthermia) is not good and can be as harmful as hypothermia. (Klossner/Hatfield, 2006) Rationale for Interventions: .

Intervention Evaluations:
Intervention: ADDED-Assess tempurature, apical pulse, and respiration rate every 4 hours. /R/ Monitoring tempurature allows for prompt intervention if tempurature is outside of beneficial range. (Klossner/Hatfield, 2006) Status: Effective Comment: 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 heat loss. (Klossner/Hatfield, 2006) Status: Effective Comment: 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 an excellent way to keep baby warm and provide family-centered care. (Klossner/Hatfield, 2006) Status: Effective Comment: 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 uneccessary heat loss at home such as avoiding drafty locations and avoiding placing baby on cold surface. (Klossner/Hatfield, 2006) Status: Effective Comment: Mom was receptive to information and stated she understood the importance of keeping baby warm.

Printed: 02/02/2011 20:08

Care Plans
Student:

Ibarra, Dolce

Patient:

x x (Pt # 18363)

Intervention: ADDED-Teach mom and dad to not overheat baby by covering or wrapping too much. /R/ Warm baby is good, hot baby (hyperthermia) is not good and can be as harmful as hypothermia. (Klossner/Hatfield, 2006) Status: Effective Comment:

Goal Evaluations:
Goal: ADDED-Keep baby's tempurature between 97.7 and 99.5 degrees Status: Reached Comment: Goal met: Baby's tempurature stayed within safe range.

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