NURSING CARE PLAN 1

Nursing Dx:
Risk for infection related to compromised immune system secondary to perineal
laceration during delivery.
Nursing Inference:
The immune system is composed of three lines of defense. A damage to one of these lines would
cause the immunity of a person to deteriorate, thus increasing the persons risk for being won
over by pathogenic microorganisms. Lacerations in the perineum during delivery causes the
mothers immune system to be vulnerable from certain pathogens and even by the normal flora
turned to opportunistic microorganisms, and thus amplify the risk of infection.
Nursing Goal:
After 2-3 days of appropriate nursing interventions, the client will verbalize understanding of
risk factors, achieve timely wound healing, and continue to be free of any symptoms of infection
during postpartum period.
Nursing Interventions:

Monitoring of vital signs, lochia (character, amount, odor, and presence of clots), fundal
height, and status of improvement of the sutured laceration.
Rationale: Alterations from normal may be signs of infection, retained fragments or sub

involution of the uterus.

Monitor temperature, check for redness, swelling, increased pain, or any abnormal
drainage on the lacerated site.
Rationale: Increased temperature accompanied by redness, swelling and pain are signs of
infection. Such assessment is done in order to know the nursing responsibilities that

needs to be done on the patient.

Proper perineal care and hygiene should be reinforced.
Rationale: Appropriate self-care of the perineum in postpartum patients reduces the risk
of pathogenic microorganism invasion. Patients consciousness should be raised and

knowledge should be reiterated in order to retain information and to promote practice.

Emphasize early ambulation and encourage her in beginning postpartal exercises with
resumption of normal activities.

Rationale: Mothers who had NSVD are allowed to ambulate 4 to 8 hours after childbirth.
Circulation of blood is promoted through regular movements thus it helps in the healing
process; prevents constipation, circulatory problems and urinary problems; promote rapid
recovery; hastens drainage of lochia improves GI and urinary functions; and provide a

sense of well-being.
Encourage to eat foods that are rich in protein and vitamin C such as citrus fruits and
guava.
Rationale: Vitamin C is known to prevent infection and promote healing. Protein is
needed for tissue repair and regeneration; meat products, nuts and legumes are rich

sources of which.
Advise and encourage to have enough rest and sleep.
Rationale: This promotes healing by reducing basal metabolic rate and allowing oxygen
and nutrients to be utilized for tissue growth, healing and regeneration.
Intake of antibacterial medications such as amoxicillin and cephalexin as per doctors
order and advise.
Rationale: Antibiotics are used to treat and prevent infections caused by susceptible
pathogens in skin structure infections.

Nursing Evaluation:
After 3 days of proper nursing interventions, the client can already verbalize understanding of
risk factors, is achieving a timely wound healing, and is free of any symptoms of infection.

NURSING CARE PLAN 2

Nursing Dx:
Risk for activity intolerance related to weakness after giving birth.
Nursing Inference:
By the time the date of birth approaches, a woman is generally tired from the burden of
carrying so much extra weight with her. In addition, most women do not sleep well during the
last month of pregnancy. Near the pregnancy, she probably was unable to find comfortable
position in bed because of the fetus activity or the presence of back or leg pain. All during labor,
she has eaten very little, if anything, and has worked very hard with little or no sleep (Pillitteri,
2007).
Nursing Goal:
After 1-2 days of appropriate nursing interventions, the patient will report measurable
increase in activity tolerance.
Nursing Intervention

Monitor vital and cognitive signs, watching for changes in blood pressure, heart and
respiratory rate; note skin pallor and/ or cyanosis and presence of confusion.
Rationale: To be updated about the contributing factors on the clients activity intolerance
and to assist client to deal with contributing factors and manage activities within

individual limits.
Promote comfort measures and provide for relief of pain.
Rationale: To promote adaptation and to enhance ability to participate in activities
Give client information that provides evidence of daily or weekly progress.
Rationale: To encourage the client to strive more and to sustain motivation
Provide information about the effect of lifestyle and overall health factors on activity
tolerance (e.g., nutrition and adequate fluid intake).
Rationale: To promote wellness

Nursing Evaluation

After 2 days of appropriate nursing interventions, the patient has reported measurable
increase in activity tolerance.

NURSING CARE PLAN 3

Nursing Dx:
Acute pain related to tissue trauma secondary to perineal laceration during delivery as
manifested by guarding behavior on the affected area, facial grimacing upon ambulation,
and verbalization of nasakit payla ti dait ko
Nursing Inference:
When bodily tissues are injured, they respond by activating a self-healing process known as the
inflammatory response. The inflammatory response is the bodys initial mechanism of tissue
repair. Blood and fluids flood the site, causing pain and inflammation but start the repair process.
(Neher, 2011)
Nursing Goal:
After 2-3 days of appropriate nursing interventions, the client will be able to report pain
reduction from 7 to 3 as will be manifested by absence of guarding behavior and facial grimacing
and verbalization of comfort.
Nursing Interventions:

Assess the level of pain experienced by the client and her ability to perform normal task such
as eating, breastfeeding and dressing.

Rationale: Assessing the pain level experienced by the client determines her capability to comply
with other interventions.

Monitor the vital signs of the patient.

Rationale: Serves as baseline data for comparison from previous measurements and will thus
determine any improvement or further deterioration of the client's condition.

Perform a comprehensive assessment of pain to include location, characteristics, onset and

duration, frequency, quality, intensity, and precipitating factors.

Rationale: Obtaining necessary information about the pain felt will help the health care provider
formulate a more individualized and appropriate intervention for the client.

Review clients previous experiences with pain and the methods found helpful for pain
control in the past through records review and interview.

Rationale: To know the extent of capability of the client, to be able to determine the threshold of
pain of the client, and to identify possible ways on how to handle the pain experienced by the
client.

Encourage the use of relaxation technique such as deep breathing and imagery.

Rationale: This creative thinking may help decrease pain perception by interrupting the
conduction of pain impulse.

Encourage the client to have an adequate rest and sleep.

Rationale: To maintain the healthy habit of the patient, to replenish energy, to facilitate pain
relied and to divert the pain felt by the client.

Ensure clients adequacy of fluid intake.

Rationale: Fluids facilitate healing. Dry tissues and mucous membranes do not heal well and
may place the woman at increased infection and increased pain.

Nursing Evaluation:
After 2 days of appropriate nursing interventions, the client was able to report pain reduction
from 7 to 3 as manifested by absence of guarding behavior and facial grimacing and
verbalization of comfort.