Health education for mothers

1. Advise the woman to eat a greater amount and variety of healthy foods, such as meat, fish, oils, nuts,
seeds, cereals, beans, vegetables, cheese and milk to help her feel strong and well (give examples of
how much to eat).
2. Along with balanced meals, breastfeeding mothers should increase fluids. Many mothers find they
become very thirsty while the baby is nursing. Water, milk, and fruit juices are excellent choices. It is
helpful to keep a pitcher of water and even some healthy snacks beside your bed or breastfeeding chair.
3. .“I will wipe my perineum from front to back after voiding and defecation.”
4. 2.“I will use warm water to rinse the perineum after elimination.”
5. 3.“I will change the perineal pad three times a day.”
6. 4.“I will perform warm sitz baths three times a day.”
7. Avoid soap, alcohol, and other drying agents
8. Cleans nipple with clear water
9. Apply lanolin for sore or cracked nipples
10. Encourage 1 glass of fluid with each nursing of infant
11. Vitamins and minerals
12. Balanced supplement for less than 1800 cal/da
13. 1.“I should feed my infant at least every 2½ hours for 15 to 20 minutes on each side.”
14. 2.“I should avoid breast-feeding during the time of breast engorgement.”
15. 3.“I should apply moist heat to both breasts for about 20 minutes before a feeding.”
16. 4.“I should gently massage the breasts during a feeding from the outer areas to the nipples.”
17. Lactation Suppression
18. Wearing a well-fitted support bra or binder
19. Avoid any breast stimulation
20. Severe breast engorgement
21. Ice packs to the breast
22. Cabbage leaves
23. Mild analgesics
24. You may start mild exercise after two weeks rest and recovery after giving birth, but more strenuous
exercise should be delayed for four to six weeks. Begin with easier exercises and increase them
gradually if you are comfortable and it does not cause pain. If you had a Cesarean, do not begin an
exercise program for at least six weeks after delivery and with your physician’s permission.

25. Sexual intercourse is appropriate when it is comfortable for you, usually six weeks after giving birth, but
is preferable to wait until your vaginal discharge is clear.

26. If you are not nursing, wear a good support bra at all times while your breasts are engorged. You may
use ice packs under the armpits and to the side of each breast during the first couple of days of
engorgement and take Tylenol® or ibuprofen for discomfort. Do not be surprised if you have a slight
elevation in temperature for a day or two while your breasts are engorged, and you should expect milk
to lbe eaking from the breasts during this period.

Providing nursing care to a postpartum woman during the first 24 hours entails the following:

Assess the woman’s pregnancy history, especially if the pregnancy was planned or unplanned as it will determine

the ability of the woman to bond with the newborn.

 Assess the labor and birth history such as the length of labor and if any analgesia or anesthesia was

used to determine any necessary procedures to be done.

 The woman would also need a postpartum course such as her activity level after birth, any

difficulties or pain felt, and if she is successful with infant feeding to determine any need for

anticipatory guidance in home care.

  Assess the woman’s general appearance because it is a reflection of how well the woman is moving

into the taking hold phase of recovery.

 Assure the woman that losing a quantity of her hair is not a sign of illness but because she is

returning to her nonpregnant state, as hair grows rapidly during pregnancy because of increased

metabolism.

 Assess for facial edema, especially for a woman with pregnancy-induced hypertension.

 Advise the woman to purchase a nursing bra that is one to two sizes larger than her pregnancy size

to allow for increase.

 Assess the woman’s breast for any cracks or fissures, and avoid squeezing the nipple. Also, assess

for signs of mastitis such as inflammation of a certain part of the breast.

 Assess the location, consistency, and height of the fundus through palpation.

 If the uterus is not firm upon palpation, massage it gently. Placing the infant on the mother’s breast

also aids in stimulating contractions.

 Lochia is expected in a postpartum woman for 2 to 6 weeks, so assessment of its characteristics is

necessary to determine if it is the normal lochia or not.

 Observe the perineum for ecchymosis, hematoma. Edema or any drainage and bleedingfrom the

stitches.

Care in Preparation for Discharge

Before the woman is discharged, she must be educated properly regarding the care of the newborn and herself

at home.

 Instruct the woman to avoid lifting heavy objects for the first three weeks after birth.

 Advise the woman to allot a rest period every day, or to rest and sleep while her newborn is also

asleep so she can regain her energy.

 Be certain that the woman is aware that she must return to the healthcare facility after 4 to 6 weeks

for examination and that she must arrange an appointment for her baby to be examined by a

pediatrician at 2 to 4 weeks of age.

 Calling or visiting 24 hours after discharge is the best way to evaluate whether the family has been

able to grasp all instructions and integrate the newborn into the family.

Care after Discharge

Risk For Pain

Risk For Pain: Defined as an increased risk of having an unpleasant sensory and emotional experience arising

from potential tissue damage.

Risk factors

 Tissue damage.

Possibly evidenced by

 [Not applicable]

Desired Outcomes

 Patient will identify appropriate methods to provide relief from pain.

 Patient will demonstrate use of relaxation skills and diversional activities as indicated.

 Patient will verbalize relief from pain and discomfort.

Nursing Interventions Rationale

Emergency situations may precipitate fear, anxiety which can raise

Assess psychological causes of pain and discomfort.
perception of pain and discomfort.

Perform pain assessment by identifying the type,

This will help in differential diagnosis and in determining the
location, characteristic, severity, and duration of the pain.
applicable treatment method.
Use a pain scale of 0-10;

Encourage the use of relaxation techniques (e.g., deep

breathing exercise) and diversional activities (e.g., To assist the client in exploring methods for the control of pain.
watching TV).

Provide comfort measures such as application of ice Ice compress decreases edema and minimizes hematoma and pain
pack into the perineum, use of sitz bath or heat lamp to sensation while heat promotes vasodilation which facilitates
episiotomy extension. resorption of hematoma.

Administer pain medication (analgesic, narcotic or

Decreases pain and anxiety; Helps promote relaxation.
sedative) as prescribed.

Abortion

Signs and Symptoms

As nurses, we are tasked with assessing our patient to provide baseline and accurate information to other

caregivers. The signs and symptoms of abortion must be identified first before ruling out any other relative

causes.

 Vaginal spotting. Vaginal spotting appears as small brownish to reddish spots of bloodcoming out of

the woman’s vaginal opening. This usually occurs when the cervix slightly dilates because the

woman may have tried to lift heavy objects or mild trauma to the abdomen occurred.

 Vaginal bleeding. Bleeding is a serious occurrence during pregnancy because it might indicate that

the cervix has opened and products of conception might be expelled.

 Cramping/sharp/dull pain in the symphysis pubis. This could occur on both sides and could be

caused by trauma or premature contractions that might cause cervical dilation.

 Uterine contractions felt by the mother. Uterine contractions can be false or true, but either of the

two could be alarming during the early stages of pregnancy because it could expel the contents of

the uterus thereby leading to abortion.

Medical Management

 Aside from our own nursing management, physicians would also have to order a series of

therapeutic management for the pregnant woman.

 Administration of intravenous fluids. Such as Lactated Ringer’s, IV therapy should be anticipated by

the nurse as well as administration of oxygen regulated at 6-10L/minute by a face mask to replace

intravascular fluid loss and provide adequate fetal oxygenation.

 Avoid vaginal examinations. The physician would also avoid further vaginal examinations to avoid

disturbing the products of conception or triggering cervical dilatation.

 The physician might also order an ultrasound examination to glean more information about the fetal

and also maternal well-being.

Nursing Assessment

 The presenting symptom of an abortion is always vaginal spotting, and once this is noticed by the

pregnant woman, she should immediately notify her healthcare provider

 As nurses, we are always the first to receive the initial information so we should be aware of the

guidelines in assessing bleeding during pregnancy.

  Ask of the pregnant woman’s actions before the spotting or bleeding occurred and identifies the

measures she did when she first noticed the bleeding.

 Inquire of the duration and intensity of the bleeding or pain felt. Lastly, identify the client’s blood type

for cases of Rh incompatibility.

Nursing Diagnosis

 Risk for deficient fluid volume related to bleeding during pregnancy

Nursing Interventions

 If bleeding is profuse, place the woman flat in bed on her side and monitor uterine contractions

and fetal heart rate through an external monitor.

 Also measure intake and output to establish renal function and assess the woman’s vital signs to

establish maternal response to blood loss.

 Measure the maternal blood loss by saving and weighing the used pads.

 Save any tissue found in the pads because this might be a part of the products of conception.

Evaluation

 The aim for evaluation is inclined towards restoring the maternal blood volume and stopping the

source of the bleeding.

 The client’s blood pressure must be maintained above 100/60 mmHg.

 The pulse rate should be below 100 beats per minute and the fetal heart rate must be at a normal

level of 120-160 beats per minute.

 The client’s urine output should be more than 30 mL/hr, and only minimal bleeding should be

apparent for not more than 24 hours.

Nursing diagnosis
Primary Nursing Diagnosis found in Nursing Care Plan for Abortion
Anticipatory grieving related to an unexpected pregnancy outcome
Common nursing diagnosis found in Nursing Care Plan for Abortion

 Anxiety
 Disabled family coping
 Dysfunctional grieving
 Hopelessness
 Powerlessness
 Risk for infection
Risk For Infection

Risk For Infection: At increased risk of being invaded by pathogenic organisms.

Risk factors

 Decreased hemoglobin.

 Invasive procedures.

 Stasis of body fluids (lochia).

 Traumatized tissues.

Desired Outcomes

 Patient will state an understanding of individual causative/risk factors.

 Patient will display white blood cell count and vital signs within expected ranges.

 Patient will display a lochia free odor.

Nursing Interventions Rationale

Monitor rate of uterine involution and nature and the amount of Infection of the uterus delays involutionand lengthen the
lochial discharge. flow of the lochia.

These symptoms reflect systemic involvement, possibly

Observe for signs of fever, chills, body malaise, anorexia,
leading to bacteremia, shock or even death if left
pelvic pain or uterine tenderness.
untreated.

Check the episiotomy site and abdominal wound (for caesarian) for
These indicates localized infection requiring immediate
signs of edema, erythema, separation of wound edges, purulent
intervention to prevent systemic involvement.
drainage.

Check for other possible sources of infection such as urinary tract

infection(urinary frequency/pain, cloudy and odoriferous urine), Differential diagnosis is critical for effective
mastitis (swelling, erythema, pain) or respiratory infection (productive management.
cough, purulent sputum, fever).

Teach and demonstrate proper hand-washing and self-care

techniques. Review appropriate handling and disposal of To prevent the spread of infectious organisms.
contaminated materials (eg., dressings, peripads, linens).

Review WBC count, hemoglobin and hematocrit levels. Increased white blood cell count indicates an
infection. Anemia often accompanies infection, delays
 the wound healing, and weaken the immune system.

To correct anemia. And possibly improves wound

Administer iron supplement as indicated.
healing.

Gram stain identifies the type of infection while cultures

Obtain a gram’s stain or culture and sensitivity if lochia is noted to and sensitivity identify the specific pathogen and can
have an odiferous smell or purulent wound discharge is observed. indicate which antibiotic is suitable to fight the
organism.

Broad spectrum antibiotic may be ordered until the

Administer IV antibiotics as ordered. results from culture and sensitivity is available at which
time organism-specific antibiotic may be started.

NCP

Assess vital signs q 15 minutes---- Provides baseline data on the maternal blood loss

Maintain bed rest or chair rest when indicated. Provide frequent rest periods and uninterrupted night time sleep.=
Systemic rest is mandatory and important throughout al phases of dse. to reduce fatigue, and improve strength.

Monitor amt. and type of bleeding.== Provide objective evidence o bleeding.

Position the mother on her left side.= To promote placental perfusion.

Restrict vaginal examination.= Prevents tearing of placenta if placenta previa is the cause of bleeding.

Assessement

S- Ø

O-

Bleeding Episodes (amount, duration)

Facial Grimace due of Pain or no complaint of pain

Abdomen soft/hard when palpated

Manifest Body Weakness

Low BP

Increased HR

Decreased RR

Fetal HR >120-160 bpm

Decreased Urine Out

Increased Urine Concentration

Pale, Cool Skin

Increased Capillary Refill (specify)

Lab. Results

Dx: Fluid Volume Deficient r/t Active Blood Loss Secondary to Disrupted Placental Implantation

Interventions:

Assess color, odor, consistency and amount of vaginal bleeding; weigh pads

Assess hourly intake and output.

Assess baseline data and note changes. Monitor FHR.

Assess abdomen for tenderness or rigidity- if present, measure abdomen at umbilicus (specify time interval)

Assess SaO2, skin color, temp, moisture, turgor, capillary refill (specify frequency)

Assess for changes in LOC: note for complaints of thirst or apprehension

Provide supplemental O2 as ordered via facemask or nasal cannula @ 10-12 L/min.

Initiate IV fluids as ordered (specify fluid type and rate).

Position Pt. in supine with hips elevated if ordered or left lateral position.

Monitor lab. Work as obtained: Hgb & Hct, Rh and type, cross match for 2 units RBCs, urinalysis, etc. Scheduled
for ultrasound as ordered.

Determine if Pt. has any objections to blood transfusions- inform physician.

Administer blood transfusion as ordered with client consent.

Monitor closely for transfusions reaction

Provide emotional support; keep Pt. and family informed of findings and continuing plan of care.

Administered prenatal vitamins and iron as ordered: provide a diet high in iron: lean meats, dark green leafy
vegetables, eggs, and whole grains.

Prepare Pt. for cesarean birth if ordered when severe hemorrhage, abruption, complete previa at term is already
experience.

Nursing Scientific
Assessment Planning Intervention Rationale Evaluation
diagnosis explanation
S-Ø Activity Insufficient After hours Evaluate Provides After hours
O- Intolerance physiological of nursing actual and comparative of nursing
Weakness or r/t Enforced or intervention perceived baseline intervention
fatigue Bed Rest psychologic the pt. will limitations of and the Pt.’s
During al energy to demonstrat deficient in provides vital signs
Exertional Pregnancy endure or ea light of information have
discomfort or Secondary complete decrease in unusual about returned to
dyspnea to Potential required or physiologic status. needed normal
for desired daily al signs of intervention range and
Abnormal heart Hemorrhag activity. intolerance s regarding manifested
rate or blood e AEB normal quality of decreased
pressure in range of life. physiologic
response to activity pt.’s vital Monitor vital or al signs of
signs. cognitive Provides activity
Electrocardiographi signs, watch baseline intolerance.
c changes for changes of data to
reflecting blood detect the
arrythmias or pressure, changes
ischemia heart and due to
respiratory intolerance.
rate; note skin
pallor and
cyanosis and
the presence
of confusion.

Adjust Prevents
activities. the pt.’s
Reduce overexertion
intensity level .
of activity or
discontinue
activities that
cause
undesired
physiological
changes. Preserves
conservatio
Increase n of energy.
exercise levels
gradually,
such as
stopping to
rest for 3 mins.
during a 10-
minute walk or
sitting down to Helps
brush hair minimize
instead of frustration
standing. and
rechannel
energy.
Provide
positive
atmosphere
while Protects the
acknowledging client from
difficulty of the injury.
situation of the
client.

Assist with Gives the

activities and chance for
provide clients’ the client to
use of enhance
assistive ability to
devices. participate
in activities.
Promote
comfort To develop
measures and individually
provide relief appropriate
of pain. therapeutic
regimens.

Provide to
other Sustains
disciplines, clients
such as O/PT, motivation.
exercise
physiologist or
psychological
counseling. Assess if
the client is
Give client responding
information to the tx.
that provides
evidence of
 daily progress.

Provide/monito
r response to
supplemental
oxygen and
medications
and changes
in treatment
regimen.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME

Subjective: Acute pain r/t STG: Independent: Goal met.

disruption of After 2hrs of
“Sobrang sakit,” as skin and tissue After 1-2hr of nursing
verbalized by the secondary to nursing intervention,
patient. cesarean intervention, - Established rapport. -To have a good the patient
section. patient will nurse-client verbalized
verbalize relationship pain
- Monitored vital signs.
decrease decreased
Objective: intensity of pain from a scale
from 8/10 to 3/10. - Assessed quality, of 8/10 – 3/20
-Pain scale= 8/10 -To establish a
characteristics, severity as evidenced
of pain. baseline data
-Teary eyed by

-(+) guarding (-) facial

behavior -To establish grimace
baseline data
-(+) facial grimace for comparison (-) guarding
in making behavior.
-Irritable - Provided evaluation and
comfortable Frequent
to assess for
-Pale palpebral environment – small talks
possible internal
conjunctiva changed bed with
bleeding.
linens and turned significant
-Skin warm to on the fan. others
touch

- Instructed to put pillow on -Calm

- V/S taken as
the abdomen when environment
coughing or moving. helps to
follows:
decrease the
BP= 110/80 anxiety of the
patient and
PR= 80 promote
likelihood of
RR= 22 decreasing pain.

T= 37.6

- To check for
diastasis recti
and protect the
area of the
incision to
improve
comfort. And to
initiate
- Instructed patient to do nonstressful
deep breathing and
 coughing exercise. muscle-setting
techniques and
progress as
tolerated, based
on the degree of
separation.
- Provided diversionary
activities. Initiate ankle
pumping, active lower
extremity ROM, and - For pulmonary
walking ventilation,
especially when
Collaborative: exercising, and
to relieve stress
- Administer analgesic as and promote
per doctor’s order. relaxation.

- To promote
circulation,
prevent venous
stasis, prevent
pressure on the
operative site.

-Relieves pain
felt by the
patient

ASSESSMENT DIAGNOSIS NURSING PLANNING INTERVENTION RATIONALE EVALUATION

ANALYSIS

Subjective: Risk for Due to an STG: Independent

infection elective
- none related cesarean After 4 -Monitor vital -To establish a Patient is
inadequate section, hours of signs baseline data expected to
primary patient’s skin nursing be free of
Objective: intervention, infection, as
defenses and tissue
secondary were patient will evidenced by
- dressing dry -Inspect dressing -Moist from
to surgical mechanically be able to normal vital
and intact and perform drainage can be
incision interrupted. understand signs and
causative wound care a source of absence of
- V/S taken as Thus, the
factors, infection purulent
wound is at
follows: risk of identify drainage from
developing signs of - Monitor white wounds,
T: 37.3 infection. infection blood count (WB - Rising WBC incisions, and
and report indicates body’s tubes.
P: 80 them to efforts to combat
health care pathogens;
R: 19 provider normal values:
accordingly. 4000 to 11,000
BP: 120/80
mm3
LTG: -these are signs
of infection
After 2-3
days of
nursing - Monitor
intervention, Elevated
patient will temperature,
achieve Redness,
timely swelling,
wound increased pain, or
healing, be purulent drainage
-Friction and
free of at incisions
running water
purulent effectively
drainage or remove
erythema, microorganisms
- Wash hands
be afebrile from hands.
and teach other
and be free Washing
caregivers to
of infection. between
wash hands
before contact procedures
with patient and reduces the risk
between of transmitting
procedures with pathogens from
patient. one area of the
body to another

- Fluids promote
diluted urine and
frequent
emptying of
bladder; reducing
- Encourage fluid stasis of urine, in
intake of 2000 ml turn, reduces risk
to 3000 ml of of bladder
water per day infection or
(unless urinary tract
contraindicated). infection (UTI).

- These
measures reduce
stasis of
secretions in the
lungs and
bronchial tree.
When stasis
- Encourage occurs,
coughing and pathogens can
deep breathing; cause upper
consider use of respiratory
incentive infections,
spirometer. including
pneumonia.
 -Antibiotics have
bactericidal
effect that
combats
pathogens

Independent:

- Administer
antibiotics
NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

Objective Cues:

 Patient has Risk for Short Term INDEPENDENT After 8º of

not yet constipation Goal: INTERVENTIONS: nursing
eliminated r/t post interventions,
since pregnancy  Ascertain the patient was
delivery
2° cesarean normal bowel  This is to able to identify
 Absence of Within 8º of functioning of determin
bruit sounds section measures to
nursing the patient, e the
 Normal about how normal prevent
interventions, infection as
pattern of many times a bowel
bowel has the patient will manifested by
day does she pattern
not yet be able to defecate client’s
returned demonstrate  Encourage verbalization of:
behaviors or intake of foods  To “Iinom ako ng
lifestyle rich in fiber increase maraming tubig
changes to such as fruits the bulk
at kakain ng
prevent of the
stool and prutas para
developing makadumi
facilitate
problem the ako.”
passage
 Promote through
adequate fluid the colon
intake.  To
Suggest promote
drinking of moist
warm fluids, soft stool
Long Term especially in
Goal: the morning to
stimulate
peristalsis
 Encourage
Within 3 days ambulation
of nursing such as
interventions, walking within  To
individual limits stimulate
the patient will
be able to contracti
ons of
maintain usual  However, since the
pattern of she has had intestine
bowel cesarean, also s and
functioning encourage prevent
adequate rest post
periods operativ
 e
complica
COLLABORATIVE: tions
 To avoid
stress on
the
 Administer cesarea
bulk-forming n
agents or stool incision/
softeners such wound
as laxatives as
indicated or
prescribed by
the physician

 To
promote
defecatio
n
S- “Wa pa gyud ko naka ihi sukad pagpanganak nako ganina”, as verbalized by the patient.

O- looks weak

-afebrile

-coherent

-4 hours postpartum

Altered urinary elimination related to perineal edema and decreased bladder tone from fetal head pressure during
birth

1. Assess amount of urine voided during labor, and reassess fundal height and position.
2. Assess what measures patient thinks would help her to void.
3. Discuss the importance of continuing to drink.
4. Discuss importance of emptying bladder.
5. Stress importance of drinking extra water during postpartum period.
6. Teach normal physiologic changes that occur after birth and the importance of preventing complications such
as urinary retention or thrombophlebitis.
7. Instruct patient to do Kegel exercises once voiding pattern is reestablished.

S- “Unsa diay ang dapat kan-on kay nidaot man ko”, as verbalized by the patient.

O-sleepy

- looks tired

-weighs 90 lbs

-5’0” in height

-conscious

-BMI is 18.2

Imbalanced nutrition, less than body requirements, related to lack of knowledge about postpartal needs.

1. Document actual height and weight.

2. Obtain nutritional history; include family, significant others, or caregiver in assessment.
3. Monitor or explore attitudes toward eating and food.
4. Encourage to take foods, which is high in protein, vitamins and minerals.
Encourage to have an adequate supply of roughage.= It is important to help restore the peristaltic action of the
bowel.

5. Suggest liquid drinks for supplemental nutrition.

Discourage beverages that are caffeinated or carbonated.= These may decrease appetite and lead to early
satiety.

6. Encourage exercise.
7. Discuss the importance of maintaining adequate caloric intake and the four basic food groups, as well as the
need for specific minerals and vitamins.

S- “Malipong ko inig lakaw nako”, as verbalized by the patient.

O-sleepy

- looks tired

-generalized weakness noted

-with the following vital signs:

T-36.5 0C

P-75bpm

R-20cpm

BP-110/70 mmHg

Activity intolerance related to stress during labor and birth.

1. Assess sleep patterns and note changes in thought process.

2. Assess the patient’s level of mobility.
3. Monitor patient’s sleep pattern and amount of sleep achieved over the past few days.
4. Encourage patient to do whatever possible like self-care and sit in chair.
5. Suggest that the client perform activities more slowly and for shorter times, resting more often, and using
more assistance as required.
6. Encourage proper nutritional intake.
7. Plan time to be with the patient, and listen actively to the client’s concern.
8. Encourage proper nutritional intake.
9. Plan time to be with the patient, and listen actively to the client’s concern.

Acute vaginal pain related to right medio lateral episiotomy as evidenced by facial grimacing.

-Provide rapport with the patient

-Monitor vital signs

-Provide a therapeutic environment

-Encourage verbalization of feelings

-Encourage verbalization of feelings

-Encourage to do diversional activities

-Encourage rest and sleep

Subjective:

“sumasakit yung tahi paminsan minsan.” as verbalized by the client.

Objective:

-facial grimace

-pain scale of 6

-slowed movement

V/S taken as follows:

Temp: 37.3

Rr: 21

Pr: 81

BP:120/70

Objective:

-NSD with episiotomy

-used single pad for 12 hours

-Temp. = 37 C

Risk for uterine infection related to episiotomy

-Monitor vital signs

-Proper perineal care and hygiene

-Emphasized early ambulation and beginning postpartal exercises with resumption of normal activities as
tolerated

-Encourage to eat foods that are rich in proteins and Vitamin C

-Encourage to have enough rest and sleep