ASSESSME EXPLANATION GOALS AND NURSING RATIONALE: EVALUATION:

NT: OF THE OBJECTIVES: INTERVENTIONS:

PROBLEM:

O: Due to episiotomy, STO: Dx: STO:

Presence of skin and tissue After 8hours of nursing >Assess and document >To note for signs of After 8hours
incision in the were mechanically interventions the patient skin conditions inflammation Of nursing interventions, the
perineal area interrupted. The will be able to understand and drainage. patient understands how to
skin is considered how to prevent infection prevent infection by verbalizing
Nursing Dx: as the first line of by verbalizing the ways on the ways on how to prevent
Risk for defense. When how to prevent infection >Monitor elevated >these are signs of infection by
infection there is a like >proper hygiene temperature, redness, infection >proper hygiene >keeping the
related to breakage, that >keeping the area clean swelling, increased area clean and dry
episiorrhaphy causes a portal of and dry pain, or purulent
entry of drainage at incision
microorganisms >Moist from drainage can
that can cause >inspect dressing be a source of infection
infection.
LTO: LTO:
After 3days of nursing Tx: >Wet area can be lodge After 3days of nursing
intervention the patient area of bacteria interventions there will be no
will be free from any signs >keep area around sign of infections like
and symptoms related to wound dry >fever
infection like >swelling
>fever
>incision may become >It serves as a first line of
red, swollen and tender defense against bacteria
Edx:
>Encourage patient to >To promote wound
further practice proper healing and boost immune
hygiene by hand system.
washing

>Instruct patient in
maintaining proper diet
food rich in vitamin C >Premature
and protein such as discontinuation of
egg, beans, nuts, meat treatment when clients
and fish begin to feel well may
result in return of infection
>Emphasized necessity
of taking antibiotics as
prescribed by the
doctor