Download Careplan_on_episiotomy

LAGUARDIA COMMUNITY COLLEGE
CITY UNIVERSITY OF New York
DEPARTMENT OF NATURAL & APPLIED SCIENCE
PRACTICAL NURSING PROGRAM
Documentation of the Nursing Process
Student’s name: Anaise Ikama
Date: October 18, 07
Client’s Initial: C.
Instructor: H. Mckenize
Admitted Medical Diagnosis: OB Labor
Client’s Objectives (s): Client will regain normal urinary elimination patterns within 2 hours after childbirth, demonstrate ability to
wipe from front to back by the second day of postpartum, and verbalize signs and symptoms of urinary tract infection to report before
being discharge from postpartum.
Assessment
Gravida: 4
Para: 0030
EDC: 10/23/07
LMP: 1/16/07
EGA: 38 weeks + 1 day
Nursing Diagnosis
1. Impaired Urinary
Elimination related to
anesthesia as evidenced
by diminished bladder
tone and sensation
Outcome evaluation
a. Client will regain
normal urinary
elimination patterns
within 2 hours after
childbirth
Admitted vital signs:
T: 97 F
P: 101
BP: 135/81
Pelvic exam:2-3/70/-2/I
Contractions were 1.5
2. Risk for infection
a. Client will
Nursing Intervention
a. Assess for bladder
distension whenever
fundal height is checked
after childbirth
Rationales
a. Assessment provides
information about
bladder distension
b. Encourage client to
void every 2 to 3 hours
after birth by assisting
client to bathroom if
possible, or to sit on
bedpan.
b. To prevent
distension of bladder
which interfere with
uterine contraction and
may cause hemorrhage
(atony).
a. Teach client to wash
a. Teaching provides
minute in length
related to laceration
approximately 5 minute during delivery as
apart.
evidenced by
Patient had a second
degree laceration
Meds: Lidocaine was
given to suppress the
pain
demonstrate ability to
wipe from front to back
by the second day of
postpartum
hands before and after
using the bathroom and
to wipe and apply
peripads front to back
b. client will verbalize
signs and symptoms of
urinary tract infection to
report before being
discharge from
postpartum
b. Teach client signs and
symptoms of urinary
tract infection to report
to care giver: frequency,
urgency, burning or pain
with urination.
3. Risk for constipation
related to laceration
during childbirth as
evidenced by fear of
stitches disruption
a. Assess usual bowel
pattern and date of last
bowel movement
a. Client will obtain
relief of constipation
within
Inform client that the
bowels tend to be
sluggish after childbirth
due to decrease in
muscle tone,
dehydration and lack of
food during labor
Reassure client that a
bowel movement is not
going to disrupt her
stitches
information the client
needs to avoid the
introduction of
pathogens into the
urinary tract.
a. To provide
information about
normal bowel habits
and current peristaltic
activity
Client may be expected
to have daily bowel
movement
Client may be fearful of
damaging perineal
incisions or
experiencing great pain
b. client will verbalize
the importance of fibers
and fluid in her diet to
prevent constipation
b. Instruct client to
stimulate bowel mobility
by eating fiber, fresh
fruits and vegetables,
drinking 8 to 10 glasses
of fluids per day
with passage of stool
b. Client may be
unfamiliar with
information and may
find new motivation to
improve diet to prevent
constipation