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