Nursing Care Plan

Problem Identified: Wound

Nursing Diagnosis: Impaired skin integrity related to altered metabolic state to allergic reactions
Cause Analysi
Cues

Objectives

Nursing
Rationale
Interventions
Subjectives:
Independent
daghan kog
STO:
Assess skin
Establish
katol katol sa
After 1-2 hours of
daily. Note the
cooperative baseline
akongtiil as
nursing
color, turgor,
stated by the
intervention the
circulation and
patient.
patient will be
sensation.
Maintaining clean,
able to identify
Maintain/
dry skin provides a
ways to promote
instruct in good
barrier to infection
Objectives:
healing
skin hygiene,
Wound
such as wash
thoroughly and
noted at
Reduces stress on
pat dry
lower
carefully
pressure points,
leftleg
Reposition
Darkening
improves blood flow
LTO:
frequently
of skin
to tissues
Encourage out
After 8 hours of
Lesion o
of bed as
scalp noted nursing
intervention the
tolerated
Cover open
patient will be
able to
lesions with

Evaluation
STO:
After 4hrs of
Nursing
Interventions, the
patient wasslightly
relieved from
edema as
evidenced by
shrunken edema
in the ankle.

LTO:
After 5 days of
giving effective
nursing

demonstrate
behaviors to
prevent skin
breakdown.

sterile dressing
Collaborative
Cilostazol
1amp; 2L
( 150mg/mL)
OD soln IVTT
Lyrica (pain) 50
mg 1 cap BID
PO

interventions, the
patient was free
from edema and
have a stable vital
signs

References: Maternal and Child Health Nursing 6th Edition by Adele Pilliteri and Health Assessment 3 rd Edition by
Weber and Kelley

Nursing Care Plan

Problem Identified: Urinary Incontinence and Retention
Nursing Diagnosis:Impaired Urinary Elimination: StressIncontinence related to transient loss of tone of the
bladderafter the delivery
Cause Analysis: During a vaginal birth, the fetal head exerts a great deal of pressure on the bladder and urethra as it
passes on the bladders underside. This pressure may leave the bladder with a transient loss of tone that, together
with the edema surrounding the urethra, decreases a womans ability to sense when she has to void. A woman who
has undergone epidural or spinal anesthesia can feel no sensation in the bladder area until the anesthetic has worn
off. (Maternal and Child Health Nursing by Adele Pilliteri 6 th Edition. Vol. 1 p. 424)
Cues

Objectives

Nursing
Intervention

Rationale

Evaluation

Subjective:
Hindi
konamamalayannanaiihi
naako as stated by the
patient.

Objectives:
Reports of loss of
sensation in the
perineum

STO:
After 8hrs of
nursing
intervention,
the patient

Encouraged
the client to
void every 24hrs
Assessed the
amount of
urine output
Taught and
encouraged
to perform
Kegels
exercise
Instruct the
patient to
have a urine
output diary
indicating
toilet voiding
and leaking
Apply
perineal
pads

Collaborative:
Administer
catheter as
indicated

-to minimized
over distention

-to strengthen
the pelvic
muscle
-allows to
identify
patterns of
voiding on the
toilet or
involuntarily
and
precipitating
factors
-to avoid
leaking urine in
the bed

-relieves and
prevent urinary
retention

References: Maternal and Child Health Nursing 6th Edition by Adele Pilliteri

Nursing Care Plan

Problem Identified: Fatigue
Nursing Diagnosis: Activity Intolerance related to increased physical exertion after delivery
Cause Analysis:As soon as birth is completed, a woman experiences total exhaustion. All during labor, she worked
hard with little or no sleep. Now, she has sleep hunger, which may make it difficult for her to cope with new
experiences and stressful situations until she has enjoyed a sustained period of sleep. (Maternal and Child Health
Nursing by Adele Pilliteri 6th Edition Vol. 1 p. 425)
Cues

Objectives

Nursing
Intervention

Rationale

Evaluation

Subjective:
nakakapagod,
tsakawala pa
akongsapatnatul
og. Kasigawang
nag labor akong
midnight as
stated by the
patient.
Objectives:
Prefer to lie
in bed
always
Appears
tired with
some
weakness
Cooperative
when asked
but limited
in
answering
Always
asking for
assistance
when doing
something

STO:
After6hrs of
nursing
intervention, the
patient will be
able to feel
rested

LTO:
After 8hrs of
complete bed
rest, the patient
will be able to
perform minimal
activities like
going to the
bathroom on her
own or walking
around the room

Encouraged
to a have a
complete bed
rest for
atleast 6hrs
Post (on the
door) visiting
schedule
time
Encouraged
the visitors to
minimized
voices
Assisted to
assume a
comfortable
position
(semi-fowlers
or side-lying)
Advised the
S.O not to let
the patient to
do heavy
things such
as lifting.

-to regain
strength
-to limit visitors
and promote rest
of patient

STO:
After 6hrs of
nursing
intervention, the
patient was able
to feel rested

LTO:

-it may add

weakness to the
patient

After 8hrs of
complete bed rest,
the patient was
able to perform
minimal activities
like going to the
bathroom on her
own or walking
around the room

References: Maternal and Child Health Nursing 6th Edition by Adele Pilliteri

Nursing Care Plan

Problem Identified: Altered Sleep Pattern
Nursing Diagnosis: Disturbed Sleeping Pattern related to Exhaustion from delivery
Cause Analysis: As soon as birth is completed, a woman experiences total exhaustion. All during labor, she worked
hard with little or no sleep. Now, she has sleep hunger, which may make it difficult for her to cope with new
experiences and stressful situations until she has enjoyed a sustained period of sleep. (Maternal and Child Health
Nursing by Adele Pilliteri 6th Edition Vol. 1 p. 425)
Cues

Objectives

Nursing
Intervention

Rationale

Evaluation

Subjective:
walatalagaakongtamangtulog
kasimga midnight naakona
start ng labor
taposnanganakakongmadaling
araw as verbalized by the
patient

Objectives:
Appears weak
Sunken eyeballs
Passive when asked
Likes to lie on bed always
Vital signs:
Bp: 130/80mmHg
P: 78 bpm
RR: 21
T: 36.7 C

STO:
After 6hrs of
nursing
intervention,
the patient
will be able to
sleep and
feels rested.

LTO:
After 2days of
rest and
sleep, the
patient will
regain her
strength
again.

Posted (on
the door)
visiting
schedule
hours
Encouraged
to have a
complete
bed rest 4 at
least 6hrs
Placed in a
(R) side
lying
position
Instructed
the S.O to
refrain from
making
noises
Assisted
needs in
order to
promote
sleep such
pillows and
bed rituals
(listening to
preferred

-to limit
visitors

-to regain
strength
-to increase
tubular
reabsorption
thus limiting
disturbance
from frequent
urination

music by the
patient)

References: Maternal and Child Health Nursing 6th Edition by Adele Pilliteri

Nursing Care Plan

Problem Identified: Constipation
Nursing Diagnosis:Risk for Constipation related to the still-present effect of relaxin on the bowel after delivery

Cause Analysis: Digestion and Absorption begin to be active again soon after birth unless a woman has had a
Ceasarian birth. Bowel sounds are active, but passage of stool through the bowel maybe slow because of the stillpresent effect of relaxin on the bowel. (Maternal and Child Health Nursing by Adele Pilliteri 6 th Edition Vol. 1 p. 242)
Cues

Objectives

Objectives:

After 1 hr of
nurse-patient
interaction, the
patient will be
able to know the
ways on how to
prevent
constipation

Nursing
Interventions
instruct to
increase fluid
intake
(810glasses/da
y)
Encourage to
eat foods rich
in fiber such
pineapple,
papaya and
oat meals
Encourage
ambulation
Demonstrate
how to do
semisquating
position
Encourage to
avoid
stopping the
urge to

Rationale
-water helps
improving stool
consistency and
fiber-rich foods
resist enzymatic
digestion

-walking
increases blood
circulation
-maximizes use of
abdominal muscle
and force of
gravity
-stopping urge to
defecate makes
more water get
absorbed from
stool

Evaluation

defecate

References: Maternal and Child Health Nursing 6th Edition by Adele Pilliteri

Nursing Care Plan

Problem Identified: Uterine Infection
Nursing Diagnosis: Risk for Infection(uterine) related to Lochial discharges

Cause Analysis:The layer adjacent to the uterine cavity becomes necrotic and is cast off as a uterine discharge
similar to a menstrual flow. This uterine flow, consisting of blood, fragments of decidua, WBC, mucous, and some
bacteria, is known as Lochia. (Maternal and Child Health Nursing by Adele Pilliteri 6 th Edition Vol. 1 p. 422)
Cues

Objectives

Nursing
Intervention
After 8hrs of
Check the
Objectives:
nursing
perineal pad
Presence of intervention, the
for any foul
patient will be
Lochia
smelling
Provideperinea
discharge(r able to know the
importance of
l care
ubra)
maintaining
Instruct how to
T: 36.7C
cleanliness in the
do proper
perineal area and
cleaning of the
will take
perineum
Instruct to
responsibility of
her own hygiene
change pads
frequently
Encourage to
have a daily
shower
Check Vital
signs
specifically the
temperature

Rationale
-foul smelling
indicates
infection

-to prevent
infection

-to prevent
bacterial growth

-prevents
bacterial growth
and provides
comfort

-rise of
temperature may
indicate infection
th
References: Maternal and Child Health Nursing 6 Edition by Adele Pilliteri

Evaluation

Nursing Care Plan

Problem Identified:risk for Self-care Deficit
Nursing Diagnosis: Risk for bathing/hygiene self-care deficit related to exhaustion from childbirth
Cause Analysis: As soon as birth is completed, a woman experiences total exhaustion. All during labor, she worked
hard with little or no sleep. Now, she has sleep hunger, which may make it difficult for her to cope with new
experiences and stressful situations until she has enjoyed a sustained period of sleep. (Maternal and Child Health
Nursing by Adele Pilliteri 6th Edition Vol. 1 p. 425)
Cues

Objectives

Subjective:
STO:
Walaakongganangm After 2hrs of
aligo, dahilpagodako nursing
intervention,
Objectives:
the patient will
be able to
Always lie on
appear clean,
bed
There are blood dressed and
well-groomed
stains in the
linen
Not well
groomed with
LTO:
unfixed hair
After 2days of
nursing
intervention,
the patient will

Nursing
Intervention
Provide
complete bed
bath
Discardbloodstained linens
and changed
it to clean
ones
Teach how to
properly clean
the perineal
area
Encouragedail
y showering
Encourage the
S.O to assist
patient when

Rationale
-promotes
comfort
-to prevent
bacterial growth

-for
independence of
her own hygiene
-to promote
proper hygiene
-

Evaluation

take
responsibility in
her own
hygiene

doing
perineal care
or bathing
Encourage the
S.o to
maintain
cleanliness
-to prevent
inside the
bacterial growth
room
Instruct the
S.O to inform
nurse when
linens are
soiled

References: Maternal and Child Health Nursing 6 th Edition by Adele Pilliteri