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 infection After 8 hours of INDEPENDENT 1. Gestational September 5, 2022 at 3:00 pm
2022 7:10 am related to nursing care, the 1. The nurse will diabetes,
impaired tissue patient will: Identify the intrapartum GOAL MET
Objective: integrity as ● The patient risk factors of infections, PROM,
● Vital evidenced by will early infection. pre-eclampsia After 8 hours of nursing care, the
Signs: second degree recognize /eclampsia, and patient was able to:
laceration and be 2. Monitor and prolonged labor ● The patient was notified
*BP-90/60mm aware of report any increase the and recognized the
Hg Scientific basis: the risk of signs and incidence of possible risk of infection.
*HR-101 bpm Susceptible to infection symptoms of infection. The patient verbalized
*RR-17cpm invasion and ● The patient infections. 2. Signs and “ay pwede diay ni ma
*Temp-37.6’c multiplication of will 3. Ensure proper symptoms of infection ang samad
● Secon pathogenic demonstrat handling of infection vary saakong perineum nurse,
d organisms, which e infection sterile according to the unsa may pwede nako
degree may compromise control to instruments body area buhaton ani?”
lacerati health. The risk of avoid and equipment involved. Assess ● The patient demonstrated
on developing infection in in terms of for the following infection control to avoid
infection the perineal labor and signs and infection in the perineal
following area. perineal symptoms: such area. The patient
operative vaginal ● The patient flushing. as redness, foul changes her perineal pad
will not 4. Demonstrate smelling, pus when bathroom use, she
birth is high when develop an correct 3. To help prevent sprays warm water on
episiotomy is infection perineal infection, any her perineal area every
performed, during the cleaning after articles such as after voiding or
forceps are used, postpartum voiding and gloves or defecating, she wears
and among period. defecation and instruments that loose cotton underwear,
women who are ● Alleviate or frequent are introduced into and the patient
primiparous and reduce the changing of the birth canal demonstrated the correct
overweight, a pain as well peripads. during labor, birth, way of patting dry the
study has found. as the 5. Promote early and the perineum which is from
As such, timely problems ambulation, postpartum period front to back with the use
related with balanced with should be sterile. of toilet paper. The
prophylactic
the adequate rest. In addition, patient was aware of the
antibiotics should
infection by 6. Educate the adherence to intake of fiber in her diet
be given. This
administeri patient about standard infection to soften stool.
current analysis ng the signs and precautions is ● The patient did not
involved 3,225 antibiotics symptoms of essential. Gloves develop infection during
women. They and as infections. should be worn the postpartum period as
were grouped prescribed 7. Demonstrate when contacting evidenced by normal
according to the by the wound care. blood, body fluid, vitals signs and the
perineal trauma doctor. or other potentially absence of signs and
experienced DEPENDENT infectious symptoms of infection.
(episiotomy 8. Administer materials. ● The patient was
and/or perineal antibiotics as 4. Changing pad administered antibiotics
tear). Log ordered by the removes moist and lessened the pain
binomial physician. medium that and the laceration was
regression and favors bacterial treated immediately. The
the likelihood ratio COLLABORATIVE: growth. Be certain patient verbalized “dili
test were used to 9. Collaborate to instruct a naman kaayo sakit,
assess the with a postpartal client in makalakaw nasad ko
consistency of the professional or proper perineal hinay hinay.”
prophylactic a physical care, including
antibiotics in therapist for wiping from front
preventing early to back so that
infection across ambulation she doesn’t bring
and E. coli organisms
the subgroups,
positioning forward from the
while suitable to the rectum. When
multivariable log client’s giving perineal
binomial condition. care, the nurse
regression 10. Collaborate must wash hands
facilitated the with the and wear gloves.
identification of dietician or a Each postpartal
factors nutritionist client should have
associated with about the their supplies and
infection. diet/meal plan should not share
to help soften them to prevent
Reference: the stool of the the transfer of
Herdman, H. & patient to pathogens from Student Nurse:
Kamitsuru, S. avoid one client to
(2018). Nanda infection. another.
International 5. The nurse should
Nursing explore ways to
Diagnoses: help the client get
Definitions and enough rest. This
classification may increase Mary Alliza De Polonia
2018-2020 (11th circulation,
ed.). New York, promote clearing
NY: Thieme respiratory
Publishers. secretions and
lochial drainage,
Humphreys ABC, and enhance
Linsell L, Knight healing and
M. Factors general
associated with well-being.
infection following Ambulation and
operative vaginal limiting the time
birth—a the client remains
secondary in obstetric
analysis of the stirrups
prophylactic encourages
antibiotics for the circulation to the
lower extremities,
prevention of promotes venous
infection following return, and
operative delivery decreases clot
randomized formation. Help
controlled trial. the client select
Am J Obstet her activities to
Gynecol exercise other
2022;XX:x.ex–x.e body parts or
x. 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. Early ambulation
is considered as
one of the
post-operative
interventions in
Enhanced
Recovery After
Surgery protocol
and women could
be ambulated
anytime from 6-8
hours
post-surgery. Early
ambulation lowers
the incidence of
developing further
complications and
infections. With
the help of
healthcare
professionals such
as physical
therapists, we can
help the mother in
her situation to
early ambulate
and perform
certain positions
to alleviate her
pain and to avoid
further
complications.
10. High fiber intake is
important for stool
softener during
the postpartum
period, especially
mothers who
undergo surgery
such as
episiotomy to
decrease the risk
of infection and
further
complications.
Defecation during
the postpartum
stage is difficult for
mothers because
of the pain
brought by it. It is
imperative to
educate and
advise the mother
by a healthcare
professional such
as a dietitian or a
nutritionist to take
adequate amounts
of fiber relative to
her situation to
avoid infection.