Cues Subjective  Minimal lochial discharg ed as verbalize d

Nursing Diagnosis

Inference

Plan/Objective Short-term goal

Nursing Intervention Independent  Vital signs, lochia (character amount, odor and presence of clots.), fundal height, and status of episiotomy monitored. Proper perineal care and hygiene were reinforced. 

Rationale

Evaluation

Risk for uterine infection related to lochia and episiotomy

Objective  with firm and contacte d uterus NSD with episiotom y Use single pads for 12 hrs.

Due to the episiotomy there is an increased risk for being invaded by pathogenic organisms. Laceration s and broken skin destroys the bodys first line of defense, the skin.

Verbalize understanding of risk factors. Identify interventions and demonstrate techniques to prevent risks of infections.

Alteration fro normal may be signs of infections, retained fragments or sub involution of the uterus.

No redness or anomalous discharge is present at episiotomy line; lochial discharge has no foul odor; temperature is not greater than 40C

 Long-term goal  Achieve timely wound healing. Continue to be free of any symptoms of infection during pos partum period. 

Appropriate self care of the perineum n postpartum patients reduces the risk of bacterial invasion. Antiseptic feminine wash or clean warm water may be used. Mothers who had NSD are allowed to ambulate 4 to 8 hrs after childbirth. Circulation of blood is promoted through regular movements thus it helps

Emphasized early ambulation and beginning post partum exercises with resumption of normal activities as tolerated.

in the healing process; prevents constipation; circulatory problems; urinary problems; promote rapid recovery; hasten drainage of lochia; improves G.I. and urinary functions; and provides a sense of wellbeing.  Encouraged to eat foods that are rich n protein and vitamin C.  Vitamin C is known to prevent infection; citrus food is rich in vitamin C. Protein is needed for tissue repair and regeneration. this promotes healing by reducing he basal metabolic rate and allowing oxygen and nutrients to be utilized for tissue growth, healing and regeneration.

Enough rest and sleep was also advised.

Dependent  Intake of antibacterial drugs such as cephalexin as doctors order and advised.  Antibiotics are used to treat and prevent infection caused by susceptible pathogens in skin structure infections.