Question

Maternity Nursing Student Nurse Independent Nursint Interventions cite source/pe Subjective Objective: 6. Dependent Nursing Interventions/ Medical Management

Maternal new born care plan postpartum. Acute pain r/t 2nd degree laceration episiotomy

Answer 1

Nursing process is an organised systematic process which involves assessment , diagnosis , planning , implementation and evaluation .

# Assessment is of two types subjective and objective

Subjective assessment - Patient verbalises acute pain at the perineal area

Objective assessment - Pain scale of 7 , presence of facial grimace and restlessness .

# Diagnosis - Acute pain related to second degree laceration episiotomy .

# Planning - After two hours of nursing intervention, the patient will be able to express comfort and relief from pain .

# Interventions include :-

1. Assess the intensity of pain of the patient using pain scale 7/10.

Rationale - to know the pain status

2. Apply ice to the episiotomy site

Rationale - to increase vasoconstriction and reduce edema and discomfort .

3. Encourage the use of sitz bath 3-4 times /day for 20minsa and bath should be cold for the first day and warm thereafter.

Rationale - sitz bath with cold water decrease edema and promote comfort . After 24hr , moist heat increases circulation to perineum and reduces edema .

4. Teach the patient on how to use sprays ,creams ,ointments to the perineal area .

Rationale - to relieve pain

5. Administer the analgesics as prescribed by the physician

Rationale - to relieve pain

6. Teaching diversional therapies

Rationale - helps in relaxation and diversion of mind from pain

7. Teach deep breathing exercises

Rationale - it helps in the relaxation of muscles

# Evaluation :-

- Goals met as evidenced by patient verbalisation of comfort and relief of pain with a pain scale of 7 to 3 after 2hrs of nursing intervention .