Page 219 - ترم ثاني كتاب تمريض صحة الام الكتروني

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Nursing Diagnosis

• Alteration in comfort: pain related to uterine involution and
. episiotomy

• . Sleep pattern disturbance
• Alteration in nutrition to less than body requirement.

• Knowledge deficit related to physiological changes of normal
postpartum, newborn care, and self-care.
• Potential for infection related to trauma and episiotomy during delivery.
Planning and Implementation

The nurse should remain beside the patient.
• Check and record the maternal vital signs every 15 minutes, or as

necessary.
• Check the uterus to ensure that it is well contracted to prevent bleeding.
• Observe the amount of lochia.

• Inspect the perineum for edema and hematoma.
• Encourage the woman to pass urine. A full bladder will prevent proper

uterine contractions, and cause uterine atony and severe postpartum
hemorrhage.
• Clean the woman, change her clothes, swab the perineum and apply

clean pad.
• Give the woman a drink or light snack if she is hungry.

• Show the mother her newborn infant.
• Put the infant to the breast as soon as possible because the infant is very
alert and sucking reflex is very strong at this time.

• . Encourage rest and sleep
• Observe the infant's cord clamp, skin color, respiration and

temperature.
• Detect and treat complications early.
• Complete the records for woman and infant.

• Transfer the woman to postnatal ward.
Evaluation (Expected Outcome)

The woman's physiological status is within normal limits, she has normal vital
signs, well-contracted uterus, normal lochia, undescended bladder, and she is free

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