POSTPARTUM
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Alteration of After 4 hours of nursing Assessed quality, To establish baseline data for Reported pain is relieved or
‘‘Sumasakit ang aking comfort: Acute pain intervention; the patient characteristics severity of comparison in making controlled from 6/10 to 2/10
pwerta’’ as verbalized by the related to surgical will experience pain pain. evaluation. Demonstrated proper
patient incision secondary to within tolerable levels Advised to do deep To decrease discomfort relaxation technique and
episiotomy breathing exercise. diversional activities
Objective: After 2 hours of nursing Provided therapeutic To aid in alleviation of pain
Pain Scale:6/10 intervention the patient environment.
Facial grimace will be able demonstrate Instructed proper Appropriate self-care of the
(+) guarding behavior comfort and ease hygiene and perineal perineum in postpartum
(+) vaginal minimal bleeding care. patient may reduces the risk
Vital Signs: Long term: Emphasized early of bacterial invasion.
BP 110/80 mmHg Patient will view the ambulation and Circulation of blood is
Temperature: 37.1 C process of labor and beginning postpartum promoted through regular
PR:81 bmp delivery as positive and exercise with assumption movements thus it helps in
RR: 19 cpm joyful experience. of normal activities as healing process
tolerated.
Instructed on activities To promote diversional
such as chatting with activities
watcher and listening to
music
Dependent:
Administer analgesic To maintain acceptable level
(Mefenamic acid) as of pain
ordered
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION
Objective data: Risk for infection At the end of 2 Instructed on proper Appropriate self-care of the Noted no signs of infection on
(+) second degree related to perineal days, repaired hygiene and perineal care. perineum in postpartum perineal area such as redness,
perineal laceration laceration perineal laceration patient may reduce the risk of presence of pus, swelling and pain
(+) minimal vaginal site will be free bacterial invasion
bleeding from signs of Instructed to wash perineal Washing site with warm water Noted early healing on perineal
infection such as area with room may dissolve sutures and may area.
redness, presence temperature tap water. lead dehiscence
of pus, swelling Inspected perineal area To assess for early signs of
and pain routinely infection for prompt
management
At the end of 5
days, signs of
healing will be
observed on the
repaired perineal
laceration site
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: ’’ Hindi ko po Knowledge deficit of After 30 mins. of nursing Assess the pre- Provides baseline data The client able to
alam kung ano ang mga appropriate food to eat intervention, the patient will pregnancy weight and about client. understand the
dapat kong kainin or iwasan during pregnancy be able to present weight of the importance of proper
na pagkain’’ as verbalized by Verbalize client. diet.
the patient. understanding on Determine the client’s To assess the usual food She able to select the
importance of proper nutritional history, that she eats even before meals that she wants to
Objective diet. including her pre- pregnancy. eat which are good
G1P0 Enumerate food to be pregnancy diet. Psychological factors sources of the nutrients
Demonstrated lack of included in her diet Determine the client’s towards eating may needed by her and the
knowledge in health After 1 day of nursing attitude towards eating. affect one person’s baby
promotion behaviors. intervention the client will be appetite and also to know The client able to
able to the client’s eating habits maintain expected
Demonstrate changes Educate the client Education provides ample weight during
in her diet as regarding the vitamins information that the pregnancy.
manifested by proper and minerals that are client may not be aware
food selection important during her of, hence leading to the
After 1 ,2 , and 3rd trimester
st nd
pregnancy during her kind of eating habits and
of nursing interventions, the pregnancy, such as diet she is following. For
client will be able to vitamin C, Folic Acid, the client to be aware of
Demonstrate iron, calcium and the needed nutrients by
adequate weight gain protein; and the her body to nourish
as expected in sources of these herself and her baby
pregnancy (3-5 lbs. in nutrients. throughout the
1st trimester, 1-2 lbs. pregnancy. Also giving
per week during the sources of these
2nd and 3rd trimester) nutrients helps the cleat
to easier familiarize
herself as what food she
may include in diet.
Plan with the client Involving the client to her
desired meals. plan of care gives the
client the feelings of
independence. It also
personalizes the plan of
care since the client does
make the choices in some
aspects of the plan.
Suggest ways that may A pleasant environment
assist the client in gives a client a relief and
eating. feeling and will not spoil
a. Ensure pleasant her appetite. And proper
environment. positioning that reduces
b. Facilitate proper the risk of aspiration and
positioning heartburn.
Instruct the client to Caffeinated beverages
avoid caffeinated may decrease the
beverages. appetite and will make
the client feel full easily.
Instruct the client to Junk foods have empty
avoid junk foods. calories that provide on
nutritional help to the
client. The weight gain
that this food may bring
is of no good for the
client and her baby.
Encouraged the client Too much food intake is
to maintain the intake not good for the body.
of the healthy foods Too much weight gain,
needed by her body which is out of the
throughout the expected, may bring
pregnancy and also in about complications,
the postpartum period. such as gestational
diabetes mellitus and
gestational hypertension.
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION
Objective Ineffective health After 8 hours nursing intervention Assess the patient’s Identifying learning Client is able to
G1P0 maintenance related to the patient will be able to current knowledge about need about client demonstrate an
Inability to perform self- inadequate knowledge of Verbalize the importance self-care measures during knowledge understanding of self-
care measure due to lack self-care measure during and understanding on self- pregnancy Proper bathing care measures during
of knowledge. pregnancy. care measure Educate client about techniques during pregnancy.
Demonstrate appropriately proper bathing technique pregnancy can help
on proper self-care during pregnancy: prevent infections Client able to perform
measure (bathing, breast Avoid hot baths, use mild and maintain good self-care measures
care, perineal care, dental soaps and avoid harsh hygiene. independently.
care, sleep, relaxation, and chemical. Client reports feeling
dressing) Instruct client about breast Breast care during more confident in her
care during pregnancy, pregnancy can help ability to take care of
avoid nipple manipulation prevent mastitis and herself during
or stimulation and report promote pregnancy.
any signs of mastitis or breastfeeding after
breast infection, mentally delivery.
prepared for
breastfeeding.
Advise client the need to Dental care during
brush and floss regularly pregnancy is
and attend regular dental important for
check-up. maintaining oral
health and
preventing
complications such
gingivitis.
Emphasize the importance Adequate sleep and
of adequate sleep and relation during
relaxation techniques pregnancy is
during pregnancy, such as important for
deep breathing technique reducing stress and
and visualization. promoting physical
and emotional well-
being.
Appropriate dressing
Teach client about during pregnancy
appropriate dressing can help to prevent
during pregnancy, complication such as
emphasize the need to varicose veins and
wear loose-fitting, promote comfort.
comfortable clothing and
avoid tight clothing that
can constrict blood flow.
