SPRINGFIELD TECHNICAL COMMUNITY COLLEGE
School of Nursing
Client's initials:_____A.A. _____Age:____26________Sex:___F__Medical Diagnosis: __________________________________
Nursing Diagnosis: __Acute
Goals:
Short Term:
Patient will report increased
comfort in one hour.
Long Term:
Patient will report tolerable level
of pain on discharge and will
verbalize understanding of pain
management at home for midline
episiotomy.
NURS 202- Nursing Care Plan
perineal pain r/t midline episiotomy AEB patient’s facial mask of pain and guarding behavior.
Interventions: Assess/Treat/Teach
Assess
Location, type and quality of pain. Review labor
and delivery record. Vital Signs.
Inspect perineum and episiotomy repair. Note
edema, ecchymosis, localized tenderness,
purulent exudate, or loss of approximation of
suture line.
Treat
Apply ice pack to perineum, especially during
the first 24 hours following delivery.
Collaborative - Administer prescribed pain
medications.
Offer to apply anesthetic cream or spray.
Offer to use witch hazel pads after voiding or
defecating.
Encourage sitz bathz at a temperature of 38 to
40 C (100-104 F) or cooler at least twice a day.
Teach
Recommend sitting with gluteal muscles
contracted over episiotomy repair.
Explain to the patient the source and reason for
the pain, its expected duration and available
treatments.
Rationale for Intervention
Indentify and direct specific needs and
appropriate interventions.
May show excess trauma to perineal tissue
and/or developing complications requiring
further evaluation/intervention.
Provides localized anesthesia, promotes
vasoconstriction, and reduces edema and
vasodilation.
To provide pain relief.
To depress response of peripheral nerves.
To reduce edema.
Increases circulation to perineum, enhances
oxygenation and nutrition of tissues, reduces
edema, and promotes healing.
Use of gluteal tightening while sitting reduces
stress and direct pressure on perineum.
To decrease anxiety and increase sense of
control.
Evaluation
Patient verbalized increased
comfort within one hour.
VS are stable and within normal
range.
On discharge patient reported
tolerable level of perineal
discomfort. She was able to
verbalize understanding of the pain
source and how it is best to
manage at home with prescribed
pain meds if necessary, sitz baths,
witch hazel pads and the use of
anesthetic cream. Described to me
the advised sitting position (gluteal
muscles contracted).