Razaele Floyd A.

Manalo
Assessment Subjective: - ³Mas lalong sumasakit yung tahi ko sa puki, medyo nilalamig at nanghihina ang katawan ko. ´ as verbalized by the client. -pain scale: 8 out of 10, with 10 as the highest Objective: - Redness around the site of episiotomy - Mild swelling is evident. - Vital signs: T: 38 °C BP:120/80 RR:17 PR:90

BSN II- A-01

Sta. Peregrina- Group 5
Planning Short term: After 1 hour of nursing intervention, the client¶s temperature will decrease from 38°C to 37°C. After 1 hour of nursing intervention, the client will be able to learn about proper perineal care and knowledge on puerperal infections. After 1 hour, the client will be able to attain stable vital signs. After 1 hour, the redness and swelling will be reduced. Long term : After 4 hours of nursing intervention, the client will have a reduced risk for infection. Intervention -monitor vital signs every 4 hours Rationale -Increases in temperature, pulse, and/ or respirations may indicate signs of infection. Report temperature greater than 37.5 °C. -to prevent contamination of the perineum and spread of infection instruct the client to wipe from front to back after each void and frequently change pads. Encourage frequent handwashing. -this helps in reducing the body temperature due to fever -promotes wound healing and cleanses surrounding tissue. - Protein, vitamin C, and iron aid in the promotion of wound healing. - For the physician to provide other Evaluation Short term: After 1 hour of nursing intervention, the client¶s temperature will decreased from 38°C to 37°C. After 1 hour of nursing intervention, the client became aware and was able to perform proper perineal care and knowledge on puerperal infections. After 1 hour, the client attained stable vital signs. After 1 hour, the redness and swelling reduced. Long term : After 4 hours of nursing intervention, the client has a reduced risk for infection. y Goal was met

Diagnosis Risk for infection related to decreased skin integrity of the perineal tissue secondary to episiotomy

Rationale Puerperal infection is an infection of the reproductive tract associated with childbirth that occurs any time up to six weeks postpartum. The standard definition of puerperal morbidity is a temperature of 38°C or higher, with temperature occurring on any 2 of the first 10 postpartum days, exclusive of the first 24 hours, and when taken by mouth by standard technique at least four times a day. When perineal wound infection occurs, it is recognized by rednedd, warmth, edema, purulent drainage, and later, gaping of the wound that had previously been well approximated.

-instruct the client on proper perineal care

-Perform tepid sponge bath to the client

-encourage sitz bath if skin is intact and pain is under control - Increase protein, vitamin C, and iron in diet.

- Inform the Physician

A Look at Contemporary Maternal.Remove episiotomy sutures at the site of infection per physician orders. al..Newborn Nursing Care. . Ref: Ladewig. .Local pain may be severe.Broad-spectrum antibiotics are used to treat postpartal wound infections until an organism sensitive antibiotic can be started. . et. . . 6th ed.If a stitch becomes infected or an abcess developed then the sutures are removed and the area is left open and allowed to drain. 6th ed.. al.Obtain wound culture and administer medications as ordered. A Look at Contemporary MaternalNewborn Nursing Care. Ref: Ladewig. et. interventions that could benefit in removal of the infection.

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