Nursing diagnosis :pencil2: (4.Knowledge deficit related to self-care :red…
Nursing diagnosis :pencil2:
4.Knowledge deficit related to self-care :red_flag:
Encourage patient to not touch or scratch the episiotomy wound to prevent infection at episiotomy wound.
Educate about hygiene: change pad every 2hrs. and after voiding, take a shower 2 times/day, shampoo q 3 times/week, change the clothes to promote good hygiene
Perineal care: clean from front to back and use clean towel to clean perineum to prevent infection.
Educate to consume high protein diet; meat, milk, egg, bean and Vit C; orange, carrot to promote wound healing.
Suggest to avoid heavy activities at least 6-8 wks to prevent trauma at the wound.
Encourage to perform postpartum exercise to promote muscle strength such as Kegel's exercise.
Cannot answer question related to self-care
3.Risk for infection at episiotomy wound :warning:
Observe s/s of infection= fever, redness&swelling at wound, abnormal lochia & bad smelling , green or yellow discharge from wound.
Assess episiotomy wound and discharge
Advise patient avoid to touching wound and scratching wound
Advice patient to change pad every 2 hrs.
Encourage patient to assess episiotomy wound
Encourage patient to clean perineum from mons pubis past to anus
Suggest patient to perform P-care with sterile technique
R E E D A
Rt. medio-lateral episiotomy
Knowledge deficit related to breastfeeding :<3:
Suggest mother to clean nipple by water
Encourage mother to collect milk in container for prevent breast engorgement.
Suggest patient to use nipple shield because of short nipple
Suggest patient in proper position for promote breastfeeding
Encourage patient to perform 4 strategies of breast feeding
Patient has short nipple, when baby sucks, mother has pain
Cannot answer question related to breastfeeding
Cannot perform breastfeeding correctly
Risk for Postpartum haemorrhage :star:
Encourage patient to consume food contain foilc acid such as meat, egg, bean, Leafy green vegetables, such as spinach.
Follow laboratory result of CBC to ensure Hb/Hct
in normal range
Assess v/s every 4 hrs for early detection of PPH
Advice patient to observe S/S of PPH such as palpitation
,sweating ,dizziness ,cool extremity ,a lot of bleeding per vagina
Advice patient to assess and massage her uterus
for promote uterine contraction prevent PPH
Encourage patient to empty bladder because full bladder can disturb uterine contraction
Prepare IV fluid for prevent fluid loss.
Medication during labour
add Synto 30 unit in IV 650cc
620 cc, 500cc ( 10 unit per 1times)
5% D/N/2 1,000 ml vein drip
Normal delivery, EBL50 ml
Change pad every 2hrs.
FH = 13 cm.