Im drawing blanks on this care plan! I am trying to use the diagnosis: Risk for pain R/T 2nd degree perineal laceration but I can not think of any short term goals besides "patient will be pain free...":confused:

My patient was a 24 yr old female; gravida 2, para 2, living 2. Healthy baby boy born at 40wks gestation. SVD*.

We were not allowed to use pain as a diagnosis in school. What nursing care will you implement with this patient along with pain management? Think about everything you could do for her. What do you expect the outcomes to be? Remember, just because a mom has other children, there is always something to teach--even with pain management. Did she have a laceration last time? Is this new for her? Hopefully, you were able to get good info from her or can still do so. I know it's hard when you have a limited amount of time with the patient, chart, nurse and you have a deadline for you plan. I don't miss those days!! Good luck!

Okay instead of pain r/t the tear...what else is mom at risk for???? She has an open cut in her genital area.....take a guess...

INFECTION! Risk for infection....

R/T laceration

R/T Breastfeeding (Mommy can get mastitis...very painful! I just had a baby 6 months ago and let me tell you! But that is another story :))

R/T Open body cavity (cervix is open after delivery)

Did mommy have an epidural? Did she have a Foley catheter? These are also places for infection

What can you do to help her?

Maybe hygeine? Soaks?

Teach pelvic rest

Take temperature

Assess for odor

What about risk for ineffective breastfeeding? That is a biggie.

What about fatigue, changes in body?

After my baby was born I was exhausted and had horrific issues with my body because of the many changes I underwent and after baby there were more changes. I had a hard time coping...hint find a nursing diagnosis with the word "coping."

This isnt too hard, but then again I just had a baby so.....Well going to bed now good luck :)

How short term of a goal are you looking for? Perhaps "pain free" is a little off, maybe try Pain will be controlled at an acceptable level, Pain rating less then 4 or something? Laceration will be free of S/sx of infection. Laceration will have no bleeding. etc.

I used ineffective breastfeeding already...and risk for infection. But all of this info has been helpful. especially "laceration will be free from infection and bleeding" Why didnt i think of that? Thanks Obtundedrn for that one