Nursing Care Plan – Skin

Scenario: A 27-year-old female patient named Aganak Nakon from Iguig, Cagayan was rushed to the emergency department of Cagayan Valley
Medical Center (CVMC) last April 28, 2022, at 8:30 in the morning with a chief complaint of labor pain. She was accompanied by her husband
and sister and was admitted at the labor and delivery unit of the hospital. The admitting diagnosis was G1P1 (10010) Pregnancy Uterine
Delivered Term Cephalic to a live birth baby girl, (2800 g, 49 cm, 43 cm, 8,9 BS 40 weeks) clear amniotic fluid via normal spontaneous vaginal
delivery (NSVD) with right medio-lateral episiotomy (RMLE) and repair.

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired skin When the baby is Short term: Independent: Short term:
“Medyo haan nak integrity larger compared to After 2-4 days of Determine client’s To clarify After 2-4 days of
pelang unay related to the vaginal rendering series of level of discomfort intervention rendering series of
komportable ta episiotomy opening, the nursing interventions and from minor aching needs and nursing interventions and
mariknak pay lang secondary to mother is health education, the to deep pain. priorities. health education, the
tay sakit na iso normal primiparous or the client will be able to: client has:
tanangek pelang iti spontaneous head of the baby is a) verbalize Inspect status of To detect signs a) verbalized
gargaraw ko”. vaginal normal in size, but reduction/absence the perineum. and symptoms of reduction/absence
delivery as the vagina does not of swelling, possible infection. of swelling,
Objective: evidenced by stretch easily, discomfort, and discomfort, and
 Normal a right medio- episiotomy is tenderness and Maintain and To reduce risk of tenderness and
spontaneous lateral cut in performed causing skin color instruct in proper dermal trauma, skin color
vaginal the perineal trauma/damage to returned to its hygiene such as improve returned to its
delivery with area, swelling the vaginal and normal state, and keeping the area circulation and normal state, and
right around the perineal tissues b) participate in around the promote comfort. b) participated in
mediolateral initial injury during normal prevention stitches clean and prevention
episiotomy. and spontaneous measures to dry. Instruct pat measures to
 Episiotomy surrounding vaginal delivery prevent drying with a clean prevent
and tissue, reddish which leads to the complications. towel after complications.
surrounding in color and alteration of the bathing and
tissue is verbal reports layers of the skin spraying warm
swollen and of slight specifically the water over the
reddish in discomfort dermis or the Long term: area and pat dry Long term:
color. and epidermis. Thus, After 1-2 weeks of with baby wipes After 1-2 weeks of
tenderness. impaired skin rendering series of after eliminating. To promote rendering series of
integrity. nursing interventions and circulation. nursing interventions and
health education, the Encourage early health education, the
client will be able to ambulation or client has displayed
display timely healing of mobilization. To prevent timely healing of
episiotomy without pushing caused episiotomy without
complications. Instruct patient to by constipation complications.
drink plenty of which can lead to
water and fiber- opening of the
rich foods. suture.

To provide
knowledge on
Teach patient how how to apply and
to apply and remove pads that
remove maternity can help maintain
perineal pads. skin integrity and
Encourage to prevent possible
change perineal occurrence of
pads every 2-4 infection.
hours.
To reduce
swelling and help
Encourage use of with the
ice packs in the management of
first 24 hours after pain.
birth.
To aid in healing
Instruct and assist process by
the mother in increasing
using sitz circulation to the
bath/warm baths perineum and
after 24 hours of prevention of
giving birth. edema.

To strengthen
Encourage Kegel’s pelvic floor
exercise. muscles.

Collaborative: For the relief of

Paracetamol 500 postpartum
mg episiotomy pain.
1 tab PO every 6
hours as ordered.