Nursing Nursing

Cues Inference Objective Rationale Evaluation

Diagnosis Intervention

Subjective Short-term Goal Independent

♀ minimal ♀ Risk for ♀ Due to the Ms. Yaldua ♀ Vital signs, ♀ Alterations from ♀No redness
lochial uterine episiotomy will… lochia normal may be or
discharge infection there is an ♀ verbalize (character, signs of infection, anomalous
verbalized r/t lochia increased understanding amount, odor & retained fragments discharge
and risk for of risk presence of or sub involution is present
Objective episiotomy being factors. clots), fundal of the uterus. at
invaded by height, & episiotomy
♀ c firm & pathogenic ♀ identify status of line;
contacted organisms. interventions episiotomy were lochial
uterus Lacerations & demonstrate monitored. discharge
& broken skin techniques has no
♀ NSD c destroys the to prevent ♀ Proper perineal ♀ Appropriate self foul odor;
episiotomy body’s first risk of care & hygiene care of the temperature
line of infection. were perineum in is not
♀ used defense, reinforced. postpartum patients greater
single pad the skin. Long-term Goal reduces the risk of than 40°C.
for 12 hrs bacterial invasion.
Ms. Yaldua Antiseptic feminine
♀ T = 37°C will… wash or clean warm
♀ achieve water may be used.
timely wound
healing. ♀ Emphasized ♀ Mothers who had NSD
early are allowed to
♀ continue ambulation & ambulate 4 to 8 hrs
to be free beginning after childbirth.
of any postaprtal Circulation of
symptoms of exercises with blood is promoted
infection resumption of through regular
during normal movements thus it
postpartum activities as helps in the
period. tolerated. healing process;
prevents
constipation,
circulatory
problems & urinary
problems; promote
rapid recovery;
hastens drainage of
lochia; improves GI
& urinary function;
& provide a sense
of well-being.
♀ Encouraged ♀ Vitamin C is known
to eat foods to prevent
that are rich infection; citrus
in protein & fruits are rich in
vitamin C. vitamin C. Protein
is needed for
tissue repair &
regeneration;
meat products, nuts
& legumes are rich
sources of which.

♀ Enough rest & ♀ This promotes

sleep was also healing by reducing
advised. basal metabolic
rate & allowing
oxygen & nutrients
to be utilized for
tissue growth,
healing &
regeneration.

Dependent

♀ Intake of ♀ Antibiotics are

antibacterial used to treat &
medications prevent infections
such as caused by
amoxicillin & susceptible
cephalexin as pathogens in skin
per doctor’s structure
order & advise. infections.
 Nursing Nursing
Cues Inference Objective Rationale Evaluation
Diagnosis Intervention

Subjective Independent

♀ “Bahala na ♀ Health- ♀ First time The parents ♀ Health teaching ♀ In some cases ♀Parents
Lola nia sa seeking parents are will… on newborn care especially that of have
kanya (baby) behaviors usually in ♀ express was given. the 1st time altered
magalaga,” r/t period of desires to parents, they have their home
as needs of a adjustment change questions & doubts & lifestyle
verbalized normal after lifestyle, on how to care for to
by the newborn postpartum to activities & their newborn; accommodate
mother. assume their environment through such the
roles as to achieve interaction these newborn;
♀ “Hindi parents & the the optimum can all be cleared they
kase needs of health of up & issues will be uttered
marunong their newborn their settled. with
magpalit ng child. Their newborn. assurance
damit ng lifestyle, ♀ Schedule of ♀ This is to ensure their
baby,” activities & ♀ participate care was consistency with ability to
exclaimed by environment in planning discussed regards to the care care for
the father. needs to be for between the they will be giving their
altered in alterations parents. to the newborn. newborn.
Objective order to in
accommodate environment, ♀ Advise on the ♀ This is to
♀ NSD the new lifestyle & newborn’s strengthen their
member of activities. safety was commitment in
♀ G1P1 their family. noted. taking the role as
♀ seek health parents.
resources to
help in ♀ Follow-up ♀ Clinical visit for
educating examinations the newborn’s
themselves after discharge assessment is very
with the for the newborn important. This is
proper care & mother were the beginning of
for newborn scheduled. the health program
of the child that
Dependent will keep the
child’s wellness.
♀ Appointment & Aside from newborn
visit for a care, family
first newborn planning
assessment methods is
usually 2 to 6 discussed during
weeks after these appointments.
delivery.