NURSING CARE PLAN ON FOUL-SMELLING LOCHIA

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BACKGROUND
SUBJECTIVE: Short-term Goal  Educate the patient  Cleaning Trace or visible redness
 Risk for A foul-smelling lochia by demonstrating washes away should not be found or
infection can occurs on a newly The Patient will verbalize on how to do any anomalous discharge;
As verbalized by the be associated delivered mother or her knowledge about the proper perineal urinary/fecal lochial discharge has no
to the after childbirth or risk factors, identify cleaning after contaminants. foul odor; temperature
patient:
presence of abortion. This is one of interventions and show voiding and Changing pad is not greater than 40°C.
skin trauma the major causes of or demonstrate some encourage the removes moist
or skin death ranking second techniques to prevent patient to change medium that After nursing
“Sobrang nahihirapan
damage from behind the postpartal risk of infection. her peripads every favors interventions,the
akong umihi. Kapag the hemorrhage. Due to the 2-3 hours. bacterial patient was able to
episiotomy episiotomy there is an growth. achieve timely healing
umiihi ako minsan may
done to the increased risk for being Long-term Goal  Keep track and  Identifies and free from further
lumalabas na parang patient, invaded by pathogenic review prenatal, factors that infection
extreme organisms. The patient will achieve intrapartal, and place client in
brown na medyo red sa
procedures timely wound healing and postpartal record. high-risk After the nursing
ano ko. Ang hirap and Lacerations and broken during postpartum period category for intervention, the
untoward skin destroys the body’s the patient will be free development/ patient was able to
gumalaw dahil sobrang
effect of first line of defense,the from any infections. spread of demonstrate the
sakit ng tahi ko.” medication. skin. When the third postpartal appropriate comfort
stage of labor is infection. measures and free from
completed, the Short-term goal:  Illustrate and  Helps prevent pain and discomfort.
OBJECTIVE: placental attachment Patient will identify or use demonstrate a cross-
site is raw, elevated, individually appropriate strict hand-washing contamination
Vital sign:
 Acute pain and dark red. The comfort measures. policy for staff, that may harm
 BP:110/80mmh related to surface is nodular, client, and visitors. the patient.
tissue owing to the numerous
g
damage and veins, and offers an Long-term goal  Always monitor the  Elevations in
 RR:20 bmp body excellent portal of entry Patient will report patient’s vital signs: vital signs
infective for microorganisms. decreased level of pain or temperature, accompany
 PR: 81 bpm
agent, as The uterine decidua is discomfort. pulse, and infection;
 TEMP:36.6C evidenced by very thin and has many respirations, chest fluctuations, or
restlessness, small openings that pain and swelling. changes in
Nausea offer a portal for
nausea and Note presence of symptoms,
Restleness autonomic pathogens. In addition, chills or reports of suggest
responses of small cervical, vaginal anorexia or alterations in
Irritability and perineal
the patient malaise. client status.
Median episiotomy lacerations, as well as
the episiotomy site,  Advocate early  Enhances flow
Used single pad for 12 hrs provide entry ports for ambulation, of lochia and
pathogens. The balanced with uterine/pelvic
resultant inflammation adequate rest. drainage.
and infection can Advance activity as
remain localized or can
extend via blood or appropriate.
lymph vessels to other
tissues  Encouraged to eat  Vitamin C is
proper type and known to
amount of food prevent
specially foods that infection;
are rich in protein citrus fruits are
& vitamin C rich in vitamin
C. Protein is
needed for
tissue repair &
regeneration
 Assess location and  Helps in the
nature of differential
discomfort or pain, diagnosis of
rate pain on a 0–10 tissue
scale. involvement in
the infectious
process.
 Always maintain  To localize
semi-fowlers infection.
position. Provide Reduces
comfort measures; muscle fatigue,
ack rubs, linen promotes
changes. relaxation and
comfort.

 Promotes
 Give instruction sense of
regarding to the general well-
maintenance of being and
cleanliness and enhances
warmth. healing.
Alleviates
discomfort
associated
with chills.

 Antibiotics are
 Intake of used to treat &
antibacterial prevent
medications such infections
as amoxicillin & caused by
cephalexin as per susceptible
doctor’s order and pathogens in
advise skin structure
infections
  This promotes
 Advice the patient healing by
to have enough reducing basal
rest and sleep metabolic rate
and allowing
oxygen &
nutrients to be
utilized for
tissue growth,
healing &
regeneration.

 Enhances
 Demonstrate uterine
proper fundal contractility,
massage. Review promotes
the importance invulation and
and timing of the passage of any
procedure placental
fragments.