LORMA COLLEGES
NURSING CARE PLAN
STUDENT NAME:
YR LEVEL AND SEC:
ASSESSMENT
Subjective:
Gather information about
the patient's medical
history, including any
previous infections,
immunocompromising
conditions, or risk factors
for infection.
Assess vital signs including
temperature, heart rate,
respiratory rate, and blood
pressure to detect any
signs of infection.
Evaluate the appearance
and characteristics of
lochia (vaginal discharge
post-delivery) for any
abnormalities, such as
excessive bleeding, foul
RELATED LEARNING
EXPERIENCE
ROTATION: AREA:
DATES: CLINICAL INSTRUCTOR:
NURSING
DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Risk for Prevent infection and -Hygiene and Infection Prevention -Proper hygiene practices
infection complications for the and infection prevention
related to postpartum patient. Educate the patient on proper measures are crucial to
recent handwashing techniques using soap reducing the risk of
childbirth, Educate the patient on and water or alcohol-based hand postpartum infections,
altered infection prevention sanitizers. which can lead to
immune strategies and proper complications such as
response, and hygiene practices. Instruct the patient to keep endometritis, wound
potential perineal and incisional areas clean infections, or sepsis.
exposure to Monitor and manage and dry, and to change pads
pathogens in any signs or symptoms regularly.
the of infection promptly.
postpartum
environment. Collaborate with the -Pain Management and Comfort To promote comfort and
healthcare team to Measures: mobility.
ensure appropriate
treatment and follow-up Administer prescribed pain
care. medications as ordered
Encourage the use of cold packs or
odor, or unusual color.
Inspect the perineal and
abdominal incision sites for
signs of inflammation,
redness, swelling, or
discharge.
Evaluate the patient's
overall hygiene practices
and knowledge of infection
prevention measures.
Objective:
sitz baths for perineal discomfort
and swelling.
-Monitoring and Assessment:
Monitor vital signs regularly,
especially temperature, to detect
any signs of fever or infection.
-Education and Counseling:
Provide education on signs and
symptoms of postpartum
infections, such as fever, abdominal
pain, foul-smelling discharge, or
increased redness and swelling at
incision sites.
Regular monitoring and
assessment of vital signs,
lochia, and incision sites
allow for early detection
and prompt management
of any signs of infection.
Patient education and
counseling empower the
patient to participate in
their care and recognize
warning signs of
potential infections,
promoting timely
intervention and
improved outcomes.