Student name : Lama Abdulaziz

Date of admission: 27-9-2021

Mode of delivery : SVD

Mother’s name : Reham almahrazi Diagnosis :day 1 post SVD with 1st degree tear

Nursing Evidenced by Expected Outcomes Nursing Evaluation

diagnosis intervention

Acute Pain Evidenced by client will report no A. asses pain level Patient will

releated to client pain or that pain in a client using a report no

childbearing verbalization management regimen valid and reliable pain or pain

of pain reduce pain to a self-report pain at functional

functional level tool , such as the level during

before she is 0-10 numerical stay in

discharged pain rating scale hospital

B. asses the client

for pain presence

routinely at
frequent intervals
, at the same as
vitals are taken

C. administer an
opioid analgesic if
indicated for
moderate to
severe pain as per
doctor order

D. encourage the
use of relaxation
techniques
(e.g.,deep
breathing )
Ineffective Evidenced by Achieves effective A.Provide support satisfactory
breastfeeding infant breast feeding and by actively breastfeeding
related to inability to infant manifests signs helping the process And
deficit latch on to of adequate intake at mother to sustained
knowledge maternal the breast correctly position suckling at
breast the baby to attain the breast
correctly a good latch on with
the nipple and adequate
encouraging her milk supply
to continue
.trying

B.Teach the
mother to
massage breast or
burp infant and
switch to other
breast when
infant's
swallowing slows
 down to enhance
the flow of milk

C.Assess breast
and nipple
.structure
Normal nipple
and breast
structure or early
detection and
treatment of
abnormalities
with continuing
support are
important for
successful
breastfeeding

D.Evaluate and
record the
infant's ability to
properly grasp
and compress the
areola with lips,
.tongue, and jaw
Risk for - Patient will A.Demonstrate Patient was
infection and maintain a able to
related to
initiate strict hand- identify
chronic behaviors to washing policy for interventions
disease limit staff, client, and to reduce and
( diabetes ) .visitors prevent risk
the spread of
of infection
infection, as B.Observe
appropriate, perineum/incision
and reduce for other signs of
infection ( REEDA
the risk of scale )
complications.
C.Demonstrate
correct perineal
cleaning after
voiding and
defecation, and
frequent
changing of
periods

D.Monitor
temperature,
pulse, and
respirations. Note
presence of chills
 or reports of
anorexia or
malaise