Can someone take a look at my care plan? Thank you so much!!!
T = 98.5 F Oral
P=64, reg, +3
R = 18, reg, unlabored
bp = 122/86
Pain = 3/10
Breast - soft, nipples intact and non-tender
Uterus: Fundus firm, U2 at midline
Perineum - mild edema
Bowel: active bowel sound x 4 quadrants
Voiding - qs, clear, yellow
Lochia - moderate rubra, no clots
Bilateral pedal non-pitting edema
Bilateral upper extremities non-pitting edema
Treatment - Ice pack, topical
Knee high TEDS
Three nursing diagosis (Priortized)
1. Risk for infection r/t mild perineum edema, high WBC post-delivery s/t 1 degree laceration from NSVD
2. Ineffective breastfeding r/t pt unable to latch infant s/t first time mother
3. Acute pain r/t "3" on pain scale of 1 - 10 d/t breastfeeding causd contraction of the uterine.
Care Plan for Risk for Infection
Long Term Goal: Patient will remain free from symptoms of infection by discharge.
Short Term Goal 1: Pt will state 3 symptoms of infection by the end of the shift.
Short Term Goal 2: Pt will demonstrate appropriate perineal care by the end of the shift.
1. Nurse will assess perineum for infection every 4 hours
2. Nurse will assess peri pad for amount and color every 4 hours.
3. Nurse will apply epifoam PRN for discomfort
4. Nurse will teach pt to inspect perineum and explain the signs that may indicates infections at beginning of shift.
5. Nurse will provide pt with ice pack PRN for discomfort