NURSING CARE PLAN Nursing Diagnosis #: Risk for infection r/t perineal suture Goal: To prevent infection Expected

Outcome: At the end of 8 hours nurse-patient interaction, the patient will be able to: Not exhibit any signs and symptoms of infection such as fever and chilling Verbalized understanding of individual risk factors. Nursing Intervention 1. Monitor vital signs especially temperature. (Rationale: A slight elevation in temperature suggests fever.) 2. Note signs/symptoms of fever, pallor and chills. (Rationale: To assess if infection is occurring) 3. Perform surgical hand washing before and after doing perineal care on the site of episiotomy. (Rationale : To prevent infection o the area and inhibit cross contamination) 4. Explain why and how infection is likely to happen (Rationale: Give the client the idea on

Evaluation After 8 hours of nursing care, the client : Did not manifest the signs of infection (fever and chilling) . TempIdentified interventions and demonstrate techniques to prevent risk for infection.

the causative factors on infections formation) 5. Do perineal care and teach the mother on the importance of proper perineal cleaning. (Rationale: Perineal area should be cleansed well to prevent the growth of microorganisms)

NURSING CARE PLAN Nursing Diagnosis #: Readiness for enhanced nutrition Goal: To promote proper nutrition. Expected Outcome: At the end of 8 hours nurse-patient interaction, the patient will be able to: Express knowledge of healthy food and fluid choices to enhance nutrition

Nursing Intervention 1. Review clients knowledge of her current nutritional needs. (Rationale: Provide baseline for further teaching and interventions.) 2. Assist clients ability to safely store and prepare the food. (Rationale: To identify dietary changes that may be helpful in attaining health goals) 3. Do a health teaching regarding the proper nutrition that is needed for both mother and newborn.

Evaluation After 8 hours of nursing care, the client :

The client was able to enumerate ways to promote proper nutrition such as verbalizing the nutritious foods that can help enhance nutrition and on how to prepare them.