Performance Task - Nursing Care Plan - Postpartum Care

Case Scenario:
Carmina is a primigravida on her 2nd day post-delivery via NSD to a healthy baby boy. She sustained 3rd degree laceration and repair; her uterus is well contracted with minimal lochia rubra
discharge. Carmina verbalizes that she feels pain whenever she voids that is why she is afraid to wash her perineal area, the nurse also notice that Carmina is not changing her perineal pads
as instructed and is not washing her hands as needed.

NURSING CARE PLAN DIAGNOSIS Patient’s Initials: C.

ASSESSMENT DIAGNOSIS GOAL & OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective Risk for Infection of Short Term Dependent After 4-6 weeks of nursing intervention,
she feels pain the Perineum related After 4-6 weeks of Administer drugs/fluid: Ms. Carmina is able to heal completely of
whenever she voids to microorganism nursing intervention,  Paracetamol  Paracetamol relieves pain and vaginal tear caused by 3 rd degree
that is why she is invasion of 3rd degree Ms. Carmina shall discomfort lacerations with absence of infection of
afraid to wash her laceration as have healing of  Anti-inflammatory: Ibuprofen  Ant-inflammatory such as Ibuprofen the perineum.
perineal area evidenced by not vaginal tear caused reduces the inflammation
changing perineal by 3rd degree  Antibiotics: Amoxicillin  Antibiotic such as Amoxicillin helps to
Objective pads as instructed lacerations with reduces the risk of infection
 3rd degree laceration and is not washing absence of infection  Laxatives or stool softener  Laxative or stool softener may be
and repair hands as needed. of the perineum. prescribed for the first week after birth
 uterus is well to prevent constipation and hard stools
contracted with
minimal lochia rubra
discharge Independent
 not changing her  Assess and monitor  To monitor for possible infection and
perineal pads as opened sutures
instructed and is not  Taking a lot of fluids  To prevent constipation
washing her hands  Regular changing of perineal pads as  To provide comfort and prevent
as needed. instructed laceration for possible infection
 Washing hands after doing perineal care  To provide cleanliness
 Complete rest with no strenuous activity  To make some time for suture to
within 4-6 weeks completely heal