Name of Patient: A.

T Age: 29 Sex: Female Chief complaint: Uterine Contractions and discomfort

Physician: Dr. Ong AOG: 39 weeks Civil Status: Not specified

DATE AND NURSING GOALS & NURSING RATIONALE EVALUATION

TIME/CUES DIAGNOSIS OBJECTIVES INTERVENTIONS

September 5, Risk for After 8 hours of INDEPENDENT 1. Gestational September 5, 2022 at 3:00 pm
2022 7:10 am infection nursing care, the 1. The nurse will diabetes,
related to patient will: Identify the risk intrapartum After 8 hours of nursing care, the
Objective: labor as ● The patient will factors of infections, PROM, patient was able to:
● Vital evidenced early recognize infection. pre-eclampsia ● The patient was notified
Signs: by second and be aware /eclampsia, and and recognized the
degree of the risk of 2. Monitor and prolonged labor possible risk of infection.
*BP-90/60mm laceration infection report any signs increase the The patient verbalized
Hg ● The patient will and symptoms incidence of “ay pwede diay ni ma
*HR-101 bpm Scientific demonstrate of infections. infection. infection ang samad
*RR-17cpm basis: infection 3. Ensure proper 2. Signs and saakong perineum nurse,
*Temp-37.6’c Susceptible control to avoid handling of symptoms of unsa may pwede nako
FHT-133-155b to invasion infection in the sterile infection vary buhaton ani?”
pm and perineal area. instruments and according to the ● The patient demonstrated
● Secon multiplicatio ● The patient will equipment in body area infection control to avoid
d n of not develop an terms of labor involved. Assess infection in the perineal
degree pathogenic infection during and perineal for the following area. The patient
lacerati organisms, the postpartum flushing. signs and changes her perineal pad
on which may period. 4. Demonstrate symptoms: such when bathroom use, she
compromise ● Alleviate or correct perineal as redness, foul sprays warm water on
health. The reduce the cleaning after smelling, pus her perineal area every
state in pain as well as voiding and 3. To help prevent after voiding or
which an the problems defecation and infection, any defecating, she wears
individual is related with the frequent articles such as loose cotton underwear,
at risk to be infection by changing of gloves or and the patient
invaded by administering peripads. instruments that demonstrated the correct
an antibiotics as 5. Promote early are introduced into way of patting dry the
opportunistic prescribed by ambulation, the birth canal perineum which is from
or the doctor. balanced with during labor, birth, front to back with the use
pathogenic adequate rest. and the of toilet paper. The
agent (virus, 6. Educate the postpartum period patient was aware of the
fungus, patient about the should be sterile. intake of fiber in her diet
bacteria, signs and In addition, to soften stool.
protozoa, or symptoms of adherence to ● The patient did not
other infections. standard infection develop infection during
parasite) 7. Demonstrate precautions is the postpartum period as
from wound care. essential. Gloves evidenced by normal
endogenous should be worn vitals signs and the
or DEPENDENT when contacting absence of signs and
exogenous 8. Administer blood, body fluid, symptoms of infection.
sources. antibiotics as or other potentially ● The patient was
ordered by the infectious administered antibiotics
Reference: physician. materials. and lessened the pain
Herdman, H. 4. Changing pad and the laceration was
& Kamitsuru, removes moist treated immediately. The
S. (2018). medium that patient verbalized “dili
Nanda favors bacterial naman kaayo sakit,
International growth. Be certain makalakaw nasad ko
Nursing to instruct a hinay hinay.”
Diagnoses: postpartal client in
Definitions proper perineal
and care, including
classification wiping from front GOAL MET
2018-2020 to back so that
(11th ed.). she doesn’t bring
New York, E. coli organisms
NY: Thieme forward from the
Publishers. rectum. When
giving perineal
care, the nurse
must wash hands
and wear gloves.
Each postpartal
client should have
their supplies and
should not share
them to prevent
the transfer of Student Nurse: Mary Alliza De
pathogens from Polonia
one client to
another.
5. The nurse should
explore ways to
help the client get
enough rest. This
may increase
circulation,
promote clearing
respiratory
secretions and
lochial drainage,
and enhance
healing and
general
well-being.
Ambulation and
limiting the time
the client remains
in obstetric
stirrups
encourages
circulation to the
lower extremities,
 promotes venous
return, and
decreases clot
formation. Help
the client select
her activities to
exercise other
body parts or
stimulate her
mind.
6. Nurses should
educate patients
at discharge on
signs and
symptoms of
infection and
when to seek
prompt treatment
(fever, persistent
pain, changes in
lochia).
7. Teach the patient
to care for their
episiotomy
incision by not
bearing when
defecating (may
need to take stool
softeners), use ice
packs to decrease
the swelling, begin
warm sitz baths
24 hours after
birth, change
 postpartum pads
every 2-4 hours,
and always wipe
front to back after
using the
bathroom and
clean the area by
spraying warm
water over the
area and patting
dry with a clean
towel. For a
C-section incision,
keep the dressing
clean and dry until
instructed to
remove. Wash
with soap and
water as
instructed and do
not scrub.
8. Broad-spectrum
antibiotics should
be administered
until cultures or
pathogens are
identified. Very ill
patients or serious
infections require
IV antibiotics.
Less severe
infections can be
treated outpatient
with oral
antibiotics.
9.