NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Pain related to uterine After 30 minutes to 2 Independent: After 2 hours of nursing
 “I’ve been cramping and hours of nursing 1. Promote perineal Decrease discomfort intervention the patient
breastfeeding Sara increased vaginal intervention the patient exercise and was able to experience
every 4 to 6 hours discharge as will experience lesser comfortable sitting lesser pain and above a
with no problems, and evidenced by pain and above a position such as: tolerable level as
she seems to be fine.” complains of pain on tolerable level as manifested by:
palpation of lower manifested by:  Kegel’s exercise Three or four times a
 “I’ve been so tired for abdomen and  Sitting position day with five times  Fever went down to
the past few days, increased lochia flow  Reduces associated succession reduces 37.5°C
even though I’m with brownish discomforts discomforts and  Have an
getting sleep, but I discharge.  Refocuses client’s improves circulation in understanding about
haven’t been hungry.” attention, promotes the area and decrease the duration of post-
positive attitude, edema. partum discomforts
 “My lower belly is very and enhances  Knows how to do
sore. I also noticed comfort Before sitting squeeze proper breathing
that my vaginal  Promotes sense of buttocks together and exercises as
discharge has general well-being sit with that position demonstrated by the
increased and and enhances reduces physical patient
changed back to a healing. Alleviates discomfort.
brownish color. It’s discomfort After 4 hours of nursing
smellier now, too.” associated with 2. Tell patient that the The patient may fix her intervention the patient
chills. pain and discomforts mind frame about the was able to experience
Objective: usually last more than 3 pain, this in return will lesser pain and above a
After 4 hours of nursing days. lessen the perception of tolerable level as
 Small amount of intervention the patient pain and her anxiety. manifested by:
lochia, brownish with will experience lesser
a strong foul odor, on pain and above a 3. Instruct patient to do Facilitates relaxation  Pain scale of 5/10
pad tolerable level as breathing exercises.  No facial grimace
 Complains of pain on manifested by: noted
palpation of lower 4. Assessed location and Helps in the differential  Calm and
abdomen  Pain scale of at least nature of discomfort or diagnosis of tissue cooperative patient
 No bladder distention 5/10 pain, rate pain on a 0– involvement in the  Demonstrated
noted  Slight irritability and 10 scale. infectious process. proper sitting
 Uterine fundus most of the time is techniques/position
nonpalpable calm 5. Assessed for non- Non-verbal cues such as
 Lung sounds clear  Less complaints of verbal pain cues. crying, grimacing, or
withdrawn behavior
  Urine clear pain after may indicate pain.
 Urinalysis findings administration of Therefore, the goals
normal medicine Promotes sense of were met.
6. Provide instruction general well-being and
Vital Signs: regarding, and assist enhances healing.
with, maintenance of Alleviates discomfort
Temperature cleanliness and warmth. associated with chills.
 100.9°F (oral) / 38.2°C
Pulse Reduces muscle fatigue,
 110 beats/min 7. Change client’s promotes relaxation and
Respiratory Rate position frequently. comfort.
 14 breaths/min Provide comfort
Blood Pressure measures; e.g., back
 118/64 mmHg rubs, linen changes.
Heat promotes
8. Apply local heat using vasodilation, increasing
heat lamp or sitz bath as circulation to the
indicated. affected area and
promoting localized
comfort.

Reduces associated
9. Administer analgesics discomforts of infection.
or antipyretics.
Pain is a lot easier to
10. Encourage the control before it
woman to ask for pain becomes severe.
medications before the
pain becomes
severe/intolerable.

Dependent: To relieve pain as fast as

1. Administer analgesic 30 minutes to 1 hour
as ordered by physician
 Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Risk for Infection related After 2 hours of nursing Independent: Alterations from normal After 4 hours of nursing
 “I’ve been to lochia discharge intervention the patient 1. Vital signs, lochia may be signs of intervention the patient
breastfeeding Sara changing back to a will experience lesser (character, amount, infection, retained was able to experience
every 4 to 6 hours brownish color with foul pain and above a odor & presence of fragments or sub lesser pain and above a
with no problems, odor tolerable level as clots), fundal height, & involution of the uterus. tolerable level as
and she seems to be manifested by: status of episiotomy manifested by:
fine.” were monitored.
 Verbalize  No redness or
 “I’ve been so tired understanding of risk 2. Proper perineal care Appropriate self care of anomalous
for the past few factors & hygiene were the perineum in discharge is present
days, even though  Identify intervention reinforced. postpartum patients at episiotomy line
I’m getting sleep, and demonstrate reduces the risk of  Lochial discharge has
but I haven’t been techniques to bacterial invasion. no foul odor
hungry.” prevent risk of Antiseptic feminine  Temperature is not
infection. wash or clean warm greater than 38°C
 “My lower belly is water may be used.  Patient was able to
very sore. I also After 4 hours of nursing verbalize
noticed that my intervention the patient 3. Emphasized early Mothers who had NSD understanding of
vaginal discharge will experience lesser ambulation & beginning are allowed to ambulate how to do post-
has increased and pain and above a Postaprtal exercises 4 to 8 hrs after partum care for the
changed back to a tolerable level as with resumption of childbirth. Circulation of perineal are
brownish color. It’s manifested by: normal activities as blood is promoted  Patient was able to
smellier now, too.” tolerated. through regular demonstrate
 Achieve timely movements thus it helps cleaning of the
Objective: wound healing in the healing process; perineal area
 Continue to be free prevents constipation,  Patient was able to
 Small amount of of any symptoms of circulatory problems & get enough sleep.
lochia, brownish infection during urinary problems;
with a strong foul postpartum period promote rapid recovery; Therefore, the goals
odor, on pad hastens drainage of were met.
 Complains of pain lochia; improves GI &
on palpation of urinary function; &
lower abdomen provide a sense of well-
 No bladder being.
distention
noted 4. Encouraged to eat Vitamin C is known to
 Uterine fundus foods that are rich in prevent infection; citrus
nonpalpable protein & vitamin C. fruits are rich in vitamin
C. Protein is needed for
  Lung sounds clear tissue repair &
 Urine clear regeneration; meat
 Urinalysis findings products, nuts &
normal legumes are rich sources
of which.
Vital Signs:
5. Enough rest & sleep This promotes healing
Temperature was also advised. by reducing basal
 100.9°F (oral) / metabolic rate &
38.2°C allowing oxygen &
Pulse nutrients to be utilized
 110 beats/min for tissue growth,
Respiratory Rate healing & regeneration.
 14 breaths/min
Blood Pressure Dependent:
 118/64 mmHg 1. Intake of antibacterial Antibiotics are used to
medications such as treat & prevent
amoxicillin & cephalexin infections caused by
as per doctor’s order & susceptible pathogens in
advise. skin structure infections.
 Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Risk for fluid volume After 8 hours of nursing Independent: After 8 hours of nursing
 “I’ve been deficit intervention the patient 1. Review prenatal and Data helpful in intervention the patient
breastfeeding Sara will experience lesser intrapartal/surgical evaluating current fluid was able to experience
every 4 to 6 hours pain and above a records for Hb level, status and replacement, lesser pain and above a
with no problems, tolerable level as operative blood loss and presence of edema. tolerable level as
and she seems to be manifested by: fluid potential for manifested by:
fine.” diuresis.
 Maintain fluid  Fluid levels in the
 “I’ve been so tired volume at a 2. Monitor BP, pulse, Hypotension, body is adequate
for the past few functional level as status of mucous tachycardia, and dry and at a functioning
days, even though evidenced by membranes, capillary mouth may reflect level
I’m getting sleep, individually refill; note presence of dehydration and  Stable vital signs
but I haven’t been adequate urinary cyanosis. hypovolemia but may  Verbalized
hungry.” output, stable vital not occur until understanding of the
signs. circulating blood volume importance of
 “My lower belly is has decreased by 30%– having adequate
very sore. I also 50%, at which time signs fluids in the body
noticed that my of peripheral
vaginal discharge vasoconstriction may be Therefore, the goals
has increased and noted. were met.
changed back to a
brownish color. It’s 3. Note character and Lochial flow should not
smellier now, too.” amount of lochial flow be heavy or contain
and consistency of clots; fundus should
Objective: fundus. Gently massage remain firmly
fundus as indicated. contracted at the
 Small amount of umbilicus. A boggy
lochia, brownish uterus results in
with a strong foul increased flow and
odor, on pad blood loss. Note: As a
 Complains of pain rule, lochial flow is
on palpation of usually decreased by
lower abdomen second postoperative
 No bladder day, thus “normal”
distention amount of flow
noted expected after vaginal
 Uterine fundus delivery would be
nonpalpable suspect for this client.
  Lung sounds clear 4. Monitor fluid intake Kidney function is a key
 Urine clear and urine output. Note index to circulating
 Urinalysis findings appearance, color, blood volume. As output
normal concentration, and decreases, specific
specific gravity of urine. gravity increases, and
Vital Signs: vice versa. Bloody urine
or urine containing clots
Temperature signifies possible
 100.9°F (oral) / bladder trauma
38.2°C associated with surgical
Pulse intervention.
 110 beats/min
Respiratory Rate 5. Encourage adequate Preferred route for
 14 breaths/min oral fluids (e.g., 6–8 replacement once
Blood Pressure glasses/day). nausea is
 118/64 mmHg resolved/peristalsis
returns. Adequate
intake allows for timely
removal of IV.

6. Provide information Maintaining adequate

in the importance of supply of fluids in our
having adequate fluids body helps our body
in the body. systems to function well
and to also avoid
dehydration.