2.

2 Brunswick Lens Model

Name of Patient: Mrs. M. M. G. Diagnosis: Postpartum Date: 11/27/17
Chief Complain pains Physician

I. Physiologic rload M ures to:

A case of Mrs. M.
lleviate
M. G., a 23 y.o. Objective es:
female housewife - Facia imace 2. ide back rubs
from Consolacion, - Pr nce of iorraphy rovide diversionary techniques/m s
Cebu. Mrs. M. M. - degr aceration sustained during delivery . Encourage deep breathing exercis
G. was admitted low ements 5. Administer analgesics as ordere y the phy icia
due to postpartum ub ive Cues:
NSVD last - in score of 3/10 as verbalized by the p nt II. Promote wound healing 80-90%
11/26.17. She 1. Keep area clean and d resolution of
delivered a live II. Physiologic Deficit B. 2. Remove wet and w led linens promptly physiologic
term female baby. Altered skin integrity 3. Reposition clie n a regular schedule and
During her Objective Cues: 4. Instruct pati to avoid touching the site psychologic
1. Ac ain: pain score of
delivery, patient - Pr sence of episiorrap 5. Eat food h in calories, proteins, vitamin A an. and problems
3/1 lated to 2nd degree
sustained a 2nd - 2nd degree laceratio stained during delivery zinc
ration sustained
degree laceration - 1 day postpartu VD 6. E rage patient to drink 8-10 glasses o ter a day
during elivery
from her - redness on i on site perilite exposure
2. Altered skin integrity:
episiotomy. - perilite ex ure management
Currently, her 2nd degree laceration III. revent infection
III. Ph logic Risk related to episiotomy 1. Cl n ncision site with app ate antimicrobial solution
fundus is 1 finger
C. for infection 3. Risk for infection: re d
breadth below. 2. Instruct patient not to to ite
ective Cues: to presence of episi aphy
3. Encourage patient to and washing frequently
- Presence of episiorraphy
4. Recommend outi ody showers when indicated
- 2nd degree laceration
5. Do perilite exposure
- 1 day postpartum
6. Administer antibiotics as ordered by the doctor
- redness on incision site
- perilite exposure management

Objectives of Care: After 2 days of student nurse to patient interaction, Goal: After 2 days of student
the patient will be able to: nurse to patient interaction, the
1. manifest a decrease in pain as evidenced by a decrease in pain patient will be able to reach an
score from 3/10 to 2/10 optimum level of functioning.
2. Manifest wound healing as evidenced by absence of fever, body
malaise, swelling, and pain
3. Remain free from infection as evidenced by absence of fever
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