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NURSING CARE PLAN CUES Subjective : NURSING DIAGNOSIS Impaired skin and tissue integrity r/t incision made in the perineum 2 delivery RATIONALE G1PO mother in labor Small vaginal opening Cannot facilitate the birth of the baby Surgical incision in the perineum made (episiotomy) Disruption of skin surface Destruction of skin layers and tissue, muscle of the perineum Impaired skin and tissue >Minimize skin and tissue impairment >Perform episiorhaphy S> Perform proper bearing down >Advise/ coach patient to push only during contraction OBJECTIVES At the end of 30 mins. 1hr.of nursing intervention the client will able to: K> Determine the purpose of episiotomy NURSING INTERVENTIONS RATIONALE EVALUATION Goal met as evidenced of :

>inform the patient if possible that episiotomy is necessary

>for client to determine reality based and to avoid perineal / vaginal laceration

Objective: (+) right mediolateral episiotomy

>performed proper bearing down technique which helps in the expulsion of the baby and tearing of perineum >delivery tolerated via NSVD

>To avoid /prevent further tissue trauma > to enlarge vaginal opening to hasten or facilitate birth; to prevent stretching of perineal muscle and connective tissues

>Deliver the baby via NSVD >performed episiotomy

(1 day post partum) Goal met as evidenced of : >Contracted uterus >No complaints of massive or profuse bleeding >perineal muscle is approximated >does not complain of dehescence

>Repair of episiotomy, this procedure is performed for perineal skin and tissue became approximated to avoid dehiscence >To prevent post partal infections since there is a break in primary defence mechanism and avoid haemorrhage

>Free from post partal infection

>perform all procedures following strict aseptic technique

A>Demonstrate appropriate behaviour to facilitate labor via NSVD

>inform the patient regarding the progress of the delivery

>for patient to be aware on the ongoing delivery. Enhances continuous appropriate follow through of instructions >encourage continuous cooperation to the process of delivery

>provide positive regards regarding the process of delivery