ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain After 8 hours of nursing 1. Assess the 1. To identify the After 8 hours of
related to intervention the patient gestational age, foetus growth, life, nursing
contractions will be able to maternal factors position, presenting interventions the
of the uterus experience a reduced and monitor part, and descent of client’s pain was
pain verbalises of fundal height, the foetus. relieved as
comfort and relief from fetal movements evidenced by the
pain. and fetal heart happiness after
rate. delivering the
2. Continuously 2. To identify the baby &
monitor the VS progression of the verbalisation of
& duration and foetus & prepare the comfort and
Objective: frequency of mother for delivery. reduction in pain.
Vital signs: contractions.
Temp – 36.6 3. Provide complete 3. To avoid the risk of
BP- 160/100 bed rest and do falls
HR-95 not leave the
RR- 21 patient.
4. Provide 4. To relieve tension
psychological and provide support.
support by
explaining the
pain and the
mother is going 5. To enhanced the
to give birth. progression of the
5. Start in oxytocin labour and relieve
as prescribed by pain.
physician
6. Perform vaginal 6. To monitor the
examination and progress of labor and
prepare the delivery of baby
mother for
delivery of the
baby
7. Provide 7. To aid in the
lithotomy delivery of the baby
position and and relieve pain.
advice the
mother to use
mouth in
breathing.
8. Explain to 8. To psychologically
mother the need prepare the mother
for episiotomy and anesthesise the
incision and perineum thereby
administer relieve pain.
lidocane
anesthetic in the
perineum.
9. Prepare the labor 9. To deliver the
room with sterile baby.
article.

NCP 2

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for uterine Short term: Independent: 1. Alteration from After 8 hours of
infection related After 8 hours of 1. Monitor vital signs normal may be signs nursing
to episiotomy nursing intervention of infection retained intervention the
the client will be able fragments or sub client:
to: involution of uterus.
- verbalized
- verbalize 2. Proper perineal 2. Appropriate self- understanding of
understanding of care and hygiene care of the perineum risk factors
risk factors in postpartum patients - identified
- Identify reduces the risk of interventions and
Objective: interventions and bacterial invasion. demonstrate
G1P1 demonstrate Antiseptic feminine techniques to
NSD episiotomy techniques to wash of clean water prevent risk for
prevent risk for may be used. infection
VS: infection.
Temp – 36.6 3. Emphasize early 3. Circulation of
BP – 100/80 ambulation and blood is promoted
RR – 20 Long term: beginning post-partal through regular
HR – 89 - Achieve timely exercises with movements and it
O2 SAT – 98% wound healing resumption of normal helps in healing
- Continue to be activities as process.
free of any tolerated.
symptoms of
infection during 4. Encourage to eat 4. Vit C. is known to
post-partum foods that are rich in prevent infection and
period. protein and vit. C protein rich foods is
neededfor tissue
repair and
regeneration.

5. Enough rest and 5. This promotes