Assessment Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Background
Subjective Risk for Mediolateral Outcome Goal: 1.Monitor a)To obtain Outcome Goal: By
“I feel there infection episiotomy, By the end of patients baseline data the end of clinical
is an burning due to the incision clincal period Vital SIgns period client will
sensation at medio begins in the client will no demonstrate an
my wound” lateral middle of the show signs of 2.Assess the b)This will understanding of
as verbalized episiotomy vaginal infection wound daily provide the pericare/wound care
by the labour opening and noting nurse with a as evidenced by
patient. extends down drainage good baseline demonstration.Upon
toward the colour and and will end of shift
-During buttocks at a character. assist in assessment client
labour medio 45-degree determining will show no signs
lateral angle. The and and infections
episiotomy primary appropriate >Goal Met
was advantage of interventions.
performed a mediolatera Short Term
due to l Goal:After 30 c)Temperatur Short Term Goal:
complication episiotomy is mins. Of 3.Assess the e is one of the After 30 mins. Of
s that the risk nursing client best indicators nursing
for anal intervention, the temperature of infection ,if intervention, the
Objective : muscle tears patient will every 4 there is an patient will
Vital Signs is much understand the hours. increase in understand the
T-38.5℃ lower. importance of temperature importance of
R.R-20 bpm caring the an infection is caring the incision
BP-120/85 incision site and likely. site and be able to
mmHg be able to manage situation.
manage d)This will >Goal Met
situation. enhance the
learning and
Long Term 4.Instruct the help the client
Goal: After 1 client about for post
week of nursing wound care hospital
care the patient procedure wound care. Long Term Goal:
will be able with her After 1 week of
back to participation e)Icepacks nursing care the
normal,infectio . will provide patient will be able
n on incision comfort to the back to normal
site and client and -infection on
Vital Signs decrease incision site
inflammation -Vital Signs
5.Use of T-36.5℃
Icepacks RR-15
BP-120/80 mmHg
>Goal Met