DATA PATHOPHYSIOLOGY GOALS
Subjective: (Explanation of the Nursing Problem;
Diagram)
Objective (PE, Labs)
>Skin is torn due to birthing process; patient has 6
. Anesthetic: If a doctor feels a person
stitches on perineal area requires an episiotomy and the person
consents, the doctor will begin by
>Afebrile
administering anesthetic.
>Conversant and coherent
I demonstrating the proper washing of
Initial Vital signs as follows:
BP:120/80mmHg
Incision: Next, a doctor will use scissors
T:36.7C or a scalpel to make an incision. For
median and mediolateral episiotomies,
SpO2:98% this begins at the posterior fourchette,
which is the very bottom of the vaginal
HR:78bpm
opening. Median episiotomies run
RR: 16cpm downward toward the anus, while
mediolateral incisions run right or left at
a 45–60 degree
I
RN Diagnosis: (PE; PES format) . evidence by temperature not going
Examination: After delivery is over, the
Risk for
doctor will use a metal retractor to
examine the vagina, cervix, and
surrounding tissues to assess the
degree of trauma. They will also perform
infection
a rectal exam.
I hand-washing and self-care techniques. Review
Stitches:. The doctor will then repair the
related to incision itself within an hour of childbirth.
For this, they will use a surgical thread or
stitch that absorbs quickly into the body
and will not require removal.
inadequat
e primary
defense
(skin):
NURSING INTERVENTIONS
STG: (After _____ hour/s the patient
will be able to ___ as evidence by)
> After 3 hours of nursing intervention
Patient will be able to understand the
importance of preventing infection to
perineal area as evidence by patient
perineal area and taking the antibiotics
as prescribe.
LTG: (After ____hours/days the patient
will be able to ___ as evidence by)
>After 7 hours of nursing intervention,
the client will be able to remain
afebrile throughout hospital stay as
above 37.4C
(Diagnostics, Therapeutics, Educative)
>Established rapport
> Monitor the client’s vital signs, especially the temperature
> Assess the client’s episiotomy wound.
> Review white blood cell count (WBC count),
hemoglobin, and hematocrit levels.
> Educate the client and family members about proper
appropriate handling and disposal of contaminated
materials
> Educate the client on how to perform proper perineal
care.
> Educate the client on identifying signs of infection and
when to notify the healthcare provider.
> Use aseptic technique for all wound care and invasive
procedures.
>Encourage the client to increase intake of high protein,
iron, and vitamin C-rich foods.
>Position the client in a semi-Fowler’s position to
facilitate the drainage of infected lochia.
>Administer IV antibiotics as ordered.
RATIONALE EVALUATION
(After ____ hour/s of nursing intervention
the ____ goals were ___________ met as
evidence by)
>To build trust and comfort to the patient.
> After 3 hours of nursing intervention
>Fever indicates that the body’s defenses are fighting off harmful
microorganisms. A temperature of more than 100.4℉ (38℃) after the Patient was able to understand the
first 24 hours of birth and two consecutive 24-hour periods may indicate importance of preventing infection to
an infectious process. The nurse should also look for other signs of
infection if the client’s temperature is elevated, regardless of the time perineal area as evidence by patient
since delivery. demonstrating the proper washing of
perineal area and taking the antibiotics as
>episiotomy wound using the REEDA criteria (redness, edema,
ecchymosis, discharge, approximation) or hardening of the operative prescribe.
area should be promptly reported and documented. Characteristics of > After 7 hours of nursing intervention, the
wound infections may include redness, edema, heat, pain, separation of
client was able to remain afebrile
the suture line, or purulent drainage.
throughout hospital stay as evidence by
> Normally, the WBC count of a postpartum woman is increased to
temperature not going above 37.4C
20,000 to 30,000 cells/mm³ due to the stress of the labor. Because of
this increase, the conventional method of detecting infection through an
elevated WBC is not of great value in the puerperium. Leukocyte counts
in the upper limits are more likely to be associated with infection than
lower counts.
>Proper hand hygiene is the primary method to prevent the spread of
infectious organisms.
> Instruct the client in proper perineal care, including wiping from front to
back so that she does not bring E. coli organisms forward from the
rectum.
> Some clients may develop an infection days after discharge. They
should be taught how to take their temperature and when to notify their
healthcare provider.
> Contamination by environmental or personnel contact renders the
sterile field unsterile, thereby increasing the risk of infection.
> Foods high in iron, such as meats, enriched cereals and bread, and
dark, green, leafy vegetables help correct anemia. high in protein and
vitamin c-rich foods are important for healing.
>Sitting in a semi-Fowler’s position or walking encourages lochia
drainage by gravity and helps prevent the pooling of infected secretions.
>A broad-spectrum antibiotic may be ordered until the results from
culture and sensitivity are available, at which time organism-specific
antibiotics may be started. If the client is continuing drug therapy at
perineal
home, stress that she must take the full course to prevent the infection
from recurring.
>Administer oxytocic agents as prescribed.
>An oxytocic agent such as methylergonovine may be prescribed for
retained placental fragments to encourage uterine contractions and

tear and
destroy the retained fragments.

stitches
Subjective:
DATA PATHOPHYSIOLOGY

(Explanation of the Nursing Problem;

GOALS

STG: (After _____ hour/s the patient

NURSING INTERVENTIONS

(Diagnostics, Therapeutics, Educative)

RATIONALE EVALUATION

(After ____ hour/s of nursing intervention

Diagram) will be able to ___ as evidence by) the ____ goals were ___________ met as
>The client verbalized “medyo masakit yung evidence by)

bandang baba ko kapag gumagalaw”

> Assess the client pain scale and perception After 5 hours of nursing intervention, the
After 5 hours of nursing intervention, > To identify the onset and intensity of the pain client reported relieved of pain as evidence
>Pain scale of 6/10 as 0 is the lowest and 10 as
the highest Narrowed Focus the client will be able to report relieve by decreased in pain scale pain scale of
of pain as evidence by decreased in > Monitor V/S and vital sign 6/10 to a manageable level 0/10
> To established a baseline data
pain scale pain scale of 6/10 to a
>Encourage verbal report s during and after nursing
Guarding behaviour manageable level 0/10 intervention > Pain is highly subjective and to identify the effectiveness of the
Objective (PE, Labs) effectiveness of the intervention.

V/S:
Facial Grimace
LTG: (After hours/days the patient will
>BP: 120/60 mmHG
be able to ___ as evidence by)
>HR: 83 BPM Verbalized felt pain in perineal area
> Administered the medication as prescribe by the Physician:
>RR: 19/minute
After 8 hours of nursing intervention, > To control bleeding
>TEMP: 37.2ºC Pain scale of 6/10
the client will verbalize sense of control >To decreased pain
>S02: 95% of response to acute situation as

Acute Pain evidenced by positive outlook to future.

> Attached Binder
>Facial Grimace After 8 hours of nursing intervention, the
client verbalized sense of control of
>Narrowed focus >Advised client to ambulate as tolerated >To reduced pain especially when moving
response to acute situation as evidenced by

> Guarding behavior positive outlook to future.

>Reposition in side lying postion >To relieve pain and facilitate good circulation
RN Diagnosis: (PE; PES formatute

Acute Pain related to post-operative procedure as

evidence by facial grimace and verbal report of felt