protection(intervention and goals) HELP!!

  1. behaviours
    (1)uterus
    -firm (a)
    -midline (a)
    -u-2 (a)
    lochia
    -[font=simsun]°odor (a)
    -scant to moderate (a)
    -rubra (1st day postpartum) (a)

    (2) perineum
    - [font=simsun]° ecchymosed (a)
    - [font=simsun]° discharge (a)
    -approximated edges (a)
    -laceration vulva (i)
    -burning sensation upon urination (i)

    (3)breast
    -soft (a)
    -smooth (a)
    -symmetrical (a)
    -[font=simsun]° dippling (a)
    -[font=simsun]° hardess (a)

    (4) nipples
    -everted (a)
    -[font=simsun]° cracks,pain, dryness (a)
    - redness (i)
    -sensitive (i)

    (1) diagnosis: risk for infection r/t bacterial invasion of the uterus
    goal: ct will remain infection free a/e/b
    -no signs of infection (redness, edema, inflammation, pain, discharge)
    intervention: teach ct about signs and symptoms of infection (redness, discharge, edema ect)
    -reinforce importance of aseptic technique

    (2) diagnosis: risk for infection r/t trauma of childbirth
    goal:
    ct will remain infection free a/e/b
    -no signs of infection (redness, edema, inflammation, pain, discharge)

    intervention:
    teach ct about signs and symptoms of infection (redness, discharge, edema ect)

    reinforce importance of aseptic technique

    encourage the use of
    -sitz baths
    -perineum bottle


    (3)diagnosis:
    risk for engorgement r/t excessive milk production

    goal:
    ct will remain free of breast engorgement a/e/b
    - breast remaining soft and smooth
    -[font=simsun]° hardness

    intervention:
    teach ct how to express milk from breast

    encourage breastfeeding q 2-4 hrs


    (4)diagnosis:risk for skin impairment r/t improper latching
    goal: ct will maintain intact skin a/e/b
    -[font=simsun]° cracks, redness, blisters, pain

    ct will demonstrate proper latching by discharge a/e/b

    -demonstrating proper latching technique

    intervention: monitor skin condition for cracks, blisters, redness

    encourage ct to squeeze a few drops of milk onto nipple after feedings




    sorry i don't know how to attach a file, i can't think of any more interventions.(i suck at nrsg process, so if it does not make sense please let me know)
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    About hope4thebest

    Joined: Sep '06; Posts: 41; Likes: 4

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  3. by   Daytonite
    Do not be disheartened. I thought you did a great job of listing the patient's symptoms! I don't know what the (A)s and (I)s mean at the end of each symptom, however. Taking all that data and coming up with nursing diagnoses is not easy at first. It's like having a bunch of jigsaw puzzle pieces and trying to fit them together into some kind of recognizable picture. Sometimes the picture (nursing diagnosis) you come up with isn't going to have nice smooth edges. You just have to work with that as best you can. And, after all, this is all new information that you are learning as well. Part of this whole care planning process at this stage of the game for you is to learn about what is going on in the puerperal stage of the new mother.

    For Diagnosis #2 (Risk for Infection R/T trauma of childbirth) I would make the interventions more individualized since have the following assessment data to support it: perineum approximated edges, laceration vulva, burning sensation upon urination. You also have enough data to support another diagnosis of Risk for Infection R/T nipple trauma since you have that they are everted, cracked, painful, dry, red, and sensitive which can be red flags of the potential to develop mastitis. It also occurs to me that you have the data to include a diagnosis of Acute Pain. NANDA does not use any official language such as breast engorgement in their diagnoses. They do, however, have three specific diagnoses that relate to breastfeeding that you might want to consider using. Ineffective Breastfeeding is a suggestion as it covers difficulties with the breastfeeding process. So, a diagnosis would be Risk for Ineffective Breastfeeding R/T knowledge deficit.

    Here are some nursing interventions I would put with Diagnosis #1 (Risk for Infection R/T bacterial invasion of the uterus):
    • In assessing the location and contractility of the uterus, monitor for the development of any extreme uterine tenderness.
    • Observe and note the amount, color and any odor of lochial discharge.
    Here are some nursing interventions I would put with Diagnosis #2 (Risk for Infection R/T trauma of childbirth):
    • Monitor vital signs per facility routine.
    • Monitor for elevated temperature and chills.
    • Inspect and monitor patient's perineum and episiotomy repair for any edema, ecchymosis, loss of approximation of the suture line or purulent drainage
    • Change perineal pads every 4 hours removing and applying them from the front to the back.
    • Note the frequency and amount of the patient's voidings.
    • Patient to take a sitz bath or cleanse herself with a perineal bottle after voiding or defecation.
    • Offer and encourage a diet high in protein, Vitamin C and iron.
    • Promote rest and sleep.
    • Show patient how to examine vaginal area using a hand mirror.
    • Show patient how to perform her own sitz bath and perineal care.
    Nursing interventions for a diagnosis of Risk for Ineffective Breastfeeding R/T knowledge deficit:
    • Assess patient's knowledge and prior experience(s) with breastfeeding
    • Provide written and verbal information about the benefits and responsibilities involved in breastfeeding
    • Teach proper care of breast and nipples.
    • Disuade the patient's use of soap on her nipples. Using soap causes further drying and a lanolin skin product may be more desirable.
    • Teach the patient to examine her nipples after each feeding.
    • For nipple eversion teach the patient to apply ice before feeding and roll the nipple between the thumb and forefinger will help to prepare for feeding.

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