NURSING DIAGNOSIS:
Acute pain related to perineal tear as evidenced by 8/10 pain rating scale and
patient’s facial expression.
Fluid volume deficit related to excess blood loss due to perineal tear as evidenced
by decreased blood pressure.
Risk for infection related to decreased in haemoglobin level as evidenced by
excess blood loss.
Anxiety related to hospital environment as evidenced by patient’s facial
expression.
Risk for injury related to perineal tear
Disturbed sleep pattern related to physical discomfort as evidenced by irritability,
drowsyness.
Knowledge deficit related to the recovery from tear as evidenced by patient’s
frequent questioning.
Assess Nursing Goal Interventio Rationale Implementa Evaluat
ment Diagnose n tion ion
Subject Fluid Fluid Assess To get Assesse Fluid
ive volume and the the d and
the
data: deficit electroly general baseli generalelectrol
Patient related to te conditi ne yte
conditio
says excess balance on of data n of balance
that she blood loss will be patient patientis
is due to maintain maintai
feeling perineal ed Assess To Assesse ned
excessi tear as and check d and upto
ve evidenced record the recorded some
thirst. by the amoun the extent
decreased amount t of amount
Object of blood of
blood
i ve bleedin loss bleeding
data: pressure.
g
Dry
lips, Admin To Adminis
sunken i ster mainta tered IV
eyes, IV in fluids to
dry fluids fluid the
mouth to the volum patient
patient e
To Encoura
Encour mainta ged
age in patient
patient fluid to drink
to volum plenty of
drink e water
plenty
of
water
To Monitor
Monito know ed the
r the the intake/o
intake/ fluid utput
output volum chart of
chart e patient
of statisti
patient cs
Assessm Nursing Goal Interventi Rationale Implement Evaluati
ent Diagnos on ation on
e
Subjectiv Risk for To Asses To get General Risk of
e data: infection reduce s the the conditio infection
Patient related the genera baselin n of is
says that to l e data patient reduced
she is decrease risk of condit of is upto
having d in infectio ion of patient assesse some
weakness haemogl d extent
n patien
obin
t
Objective level as
data: Dull evidence To Hb
Check
facial d by know level of
the hb
expressio excess the patient
level
n blood of hb is
loss. patien level checked
t of I.e.,
patient 9
gm/dl.
Monit
or the To Monitor
vital know ed the
signs the vital
of vital signs of
patien signs patient
t of
patient
Admi
nister To Admini
antibi reduce stered
otics the risk antibiot
as of ics as
prescr infecti prescrib
ibed on ed
by by
doctor doctor.
.
Assessme Nursing Goal Interventi Rationale Implement Evaluati
nt Diagnose on ation on
Subjective Anxiety To Assess To Assess Anxiety
data: related reduc the know ed the level of
Patient to e the general the genera patient is
says that hospital anxiet conditi baselin l reduced
she is environme y on e data conditi upto
having nt as level on some
fear about evidenced of of of extent
hospital by patien patient patient
environme patient’s t To
nt facial know Assess
expression Assess the ed the
Objective the anxiet anxiet y
data: anxiety y level level of
Facial level of patient
expression of patient by
, patient depres
Frequent sion
questionin anxiet y
g stress
scale
5/10.
Provid
To ed
reduce knowl
Provid edge
anxiet
e regardi
y level
knowle ng her
of
dge conditi
patient
regardi on
ng her
conditi Provid
on To ed
reduce psycho
Provid logical
e anxiet
y level suppor t
psycho
logical of
patient Explai
suppor ned to
t To patient
about
Explai reduce
hospita
n to anxiet
l
patient y level
facility
about of
hospita patient
l
facility
NURSING DIAGNOSIS BASED ON NURSING THEORIES:
1st diagnose is based on Virginia Henderson’s Need theory, aspect is avoid
dangers in the environment & avoiding injuring others.
Acute pain related to perineal tear as evidenced by 8/10 pain rating scale and patient’s
facial expression.
2nd diagnose is based on Virginia Henderson’s Need theory, aspect is eat and
drink adequately.
Fluid volume deficit related to excess blood loss due to perineal tear as evidenced by
decreased blood pressure.
3rd diagnose is based on Florence Nightingale’s Environmental theory, aspect is
Sanitation.
Risk for infection related to decreased in haemoglobin level as evidenced by excess
blood loss.
4th diagnose is based on The Abdellah Theory, aspect is supporting patient’s
emotional need.
Anxiety related to hospital environment as evidenced by patient’s facial expression.
HEALTH EDUCATION:
Care of perineal tear:
Explain about care to be taken while cleaning perineal area.
Taught to maintain personal hygiene
Taught about to maintain perineal hygiene to prevent infection.
Breast feeding:
Encouraged her for early breast feeding
Explain importance of colostrum it’s advantages.
Advice her to give small and frequent feed to prevent aspiration. Informed
her to place the baby’s head at side lying position after feed
Postnatal care:
Educate about postnatal care
Postnatal diet
Regular checkup
Importance of family planning method.
SUMMARY:
My client Manpreet Singh was an intranatal mother. She had perineal tear during
vaginal delivery. Her gestational age is 36 weeks. She delivered a normal baby.
Condition of mother and baby was stable.
CONCLUSION:
My client was an intranatal mother came with uterine contraction and back pain.
Delivered normally by implementing proper observation the perineal tear is cured.
Mother and baby is stable now.
BIBLIOGRAPHY
Dutta D.C. ; Textbook of obstetrics; published by New Central Book agency LTD;
6th edition ; 2004; page no., 163-165.
Jacob annama; A compreshensive textbook of midwifery ; published by jaypee
brothers, medical publishers, New Delhi; page no. 257-258.
Fraser. Diane; Myles textbook for midwives; published by Elsevier Ltd; 5th
edition ; 2009; page no. 186-188.
NURSING DIAGNOSIS:
Acute pain related to incision as evidenced by 8/10 pain rating scale and patient’s
facial expression.
Fluid volume deficit related to excessive blood loss as evidenced by low blood
pressure and increased pulse rate.
Impaired skin and tissue integrity related to incision made in perineum area as
evidenced by observation.
Risk for fetal injury related to prolonged labor as evidenced by reported
experience of fatigue and fetus has not descended into birth canal.
Anxiety related to hospital environment as evidenced by patient’s facial
expression.
Disturbed sleep pattern related to physical discomfort as evidenced by irritability,
drowsyness.
Knowledge deficit related to the recovery as evidenced by patient’s frequent
questioning.
Assess Nursing Goal Interventio Rationale Implementa Evaluat
ment Diagnose n tion ion
Subject Fluid Fluid Assess To get Assesse Fluid
ive volume and the the d and
the
data: deficit electroly general baseli generalelectrol
Patient related to te conditi ne yte
conditio
says excessive balance on of data n of balance
that she blood loss will be patient patientis
is as maintain maintai
feeling evidenced ed Assess To Assesse ned
excessi and check d and upto
by low
ve record the recorded some
thirst. blood
the amoun the extent
pressure amount t of amount
Object and of blood of
i ve increased bleedin loss bleeding
data: pulse rate. g
Dry
lips, Admini To Adminis
sunken ster IV mainta tered IV
eyes, fluids in fluids to
dry to the fluid the
mouth patient volum patient
e
Encour To Encoura
age mainta ged
patient in patient
to fluid to drink
drink volum plenty of
plenty e water
of
water
Monito To Monitor
r the know ed the
intake/ the intake/o
output fluid utput
chart volum chart of
of e patient
patient statisti
cs
Assess Nursing Goal Interventio n Rationale Implement Evaluati
ment Diagnos ation on
e
Subject Impaire To Inform To Inform Skin and
ive d skin minimi the determi ed the tissue
data: and ze skin patient ne patient impairm
Patient tissue and (if reality that ent is
says integrity tissue possible based episioto minimiz
that she related impair ) that and to my ed
is to ment. episioto avoid is
unable incision my is perineal necessa
upto
to made in laceratio ry.
necessar some
deliver perineu y. n extent
baby. m area Advice To
as patient prevent Advice
Objecti further d
evidenc to push patient
ve tissue
ed only
data: trauma to push
during only
Observ by contracti
ation during
observat on. contrac
ion. tion.
To
Perform
enlarged Perfor
e episioto med
vaginal
my. episioto
opening
Provide my.
For
informat Provide
patient
ion d
to to be
aware informa
patient tion
regardin on the
to
g the ongoing
patient
progress delivery
regardi
of the ng the
delivery.
progres
s of the
To deliver
Provide
encoura y.
positive
ge Provide
regards
continuo d
regardin
us positive
g the
cooperat regards
process
ion regardi
of ng the
delivery. to
the process
process of
of deliver
delivery. y.
Assessme Nursing Goal Intervention Rationale Implementat Evaluati
nt Diagnos ion on
e
Subjectiv Risk for Risk Assess To Assessed Risk for
e data: fetal for FHR know FHR fetal
Patient injury fetal manually the manually injury is
says related injur or fetal or reduced.
to y electronic heart electroni
that she prolonge will ally. rate. cally.
is d be Note To Noted of
tired redu of know the
labor ced. the the frequenc
and does as frequenc frequ y with
evidence y with ency which
not know d which the of the
how much uterus uterin uterus
longer she by contracts. e contracts
is able to reported contra .
push. experien ction.
ce of To Identifie
Objective fatigue Identify know d
data: and fetus maternal the maternal
Labor has factors condit factors
prolonged such as ion of such as
to over 24 not dehydrati patien dehydrat
hours. descende on, t. ion,
Fetus has d acidosis, acidosis,
not anxiety. anxiety.
descended into To Monitore
into birth birth Monitor check d fetal
canal. canal. fetal the descent
descent delive in birth
in birth ry of canal in
canal in baby. relation
relation to ischial
to ischial spine.
spine. To Noted
Note check odor and
odor and the change
change in odor in color
color of and of
amniotic color amniotic
fluid with of fluid
prolonge amnio with
d rupture tic prolonge
of fluid. d rupture
membran of
membra
es.
nes.
NURSING DIAGNOSIS BASED ON NURSING THEORIES:
1st diagnose is based on Virginia Henderson’s Need theory, aspect is avoid
dangers in the environment & avoiding injuring others.
Acute pain related to incision as evidenced by 8/10 pain rating scale and patient’s
facial expression.
2nd diagnose is based on Virginia Henderson’s Need theory, aspect is eat and
drink adequately.
Fluid volume deficit related to excessive blood loss as evidenced by low blood
pressure and increased pulse rate.
3rd diagnose is based on Dorothea Orem’s Self-Care theory, aspect is Self--Care
Requisite - Health Deviation.
Impaired skin and tissue integrity related to incision made in perineum area as
evidenced by observation.
4th diagnose is based on Dorothea Orem’s Self-Care theory, aspect is Self--Care
Requisite - Health Deviation.
Risk for fetal injury related to prolonged labor as evidenced by reported experience of
fatigue and fetus has not descended into birth canal.
HEALTH EDUCATION:
Diet:
Advice her to take calcium and iron rich diet.
Advice her also to take fibre rich diet
Advice her to take medication as prescribed by doctor.
Breast feeding:
Encouraged her for early breast feeding
Explain importance of colostrum it’s advantages.
Advice her to give small and frequent feed to prevent aspiration. Informed
her to place the baby’s head at side lying position after feed
Postnatal care:
Educate about postnatal care
Postnatal diet
Regular checkup
Importance of family planning method.
Exercise:
Advice the patient for postnatal exercise.
SUMMARY:
My client Rubina Kouser was an intranatal mother. She had Vaccum extraction
vaginal delivery. Her gestational age is 38 weeks. She delivered a normal baby.
Condition of mother and baby was stable.
CONCLUSION:
My client was an intranatal mother came with uterine contraction and back pain.
Delivered normally by implementing proper observation. Mother and baby is stable
now.
