Theoretical Foundations Of Nursing Dr. Lisa Capps Fac 828019

NRG5000 Theoretical Foundations Of Nursingdr Lisa Capps Faculty1nur4

Develop a comprehensive postpartum care plan that includes patient information, nursing diagnosis, assessment data, patient outcomes, interventions with rationales, and evaluation for each outcome. The plan should focus on a mother with a second-degree perineal laceration following vaginal delivery, taking into account her specific clinical situation, medications, prenatal and labor history, and postpartum status. For each diagnosis, clearly define both short-term measurable outcomes and specific nursing actions aimed at achieving those outcomes. Include at least two patient-centered outcomes with criteria that are SMART (specific, measurable, attainable, relevant, and time-bound), and provide detailed interventions with scientific rationales. The evaluation should reflect whether each outcome was met, partially met, or unmet, and include a revised plan if necessary.

Paper For Above instruction

The postpartum period is a critical phase in maternal care, requiring thorough assessment, precise diagnosis, and targeted nursing interventions to promote recovery, comfort, and well-being. This paper presents a comprehensive postpartum care plan for a mother who experienced a second-degree perineal laceration during vaginal delivery, considering her unique clinical characteristics, lab data, medication regimen, and cultural background. The plan aims to facilitate healing, manage pain, prevent infection, and support maternal-infant bonding, ultimately ensuring optimal health outcomes for both mother and newborn.

Patient Demographics and Medical Background

The mother, identified as K.H., is a primigravida with a singleton pregnancy, delivering at 39 weeks gestation. Her prenatal course was uncomplicated except for prenatal Group B Streptococcus colonization, for which she received antibiotics during labor. She is self-reported to be in good health, with no prior medical or surgical history. Her medications include acetaminophen, docusate, and ibuprofen, used for pain and stool softening as needed. Her blood type is A positive, and she refused anesthesia during labor. She delivered vaginally, and her newborn, N., is a healthy female with an initial APGAR score of 8 at one minute and 9 at five minutes. The mother sustained a second-degree perineal laceration, which is expected to heal with appropriate nursing care.

Nursing Diagnosis

Based on the assessment data, the primary nursing diagnosis is “Pain related to second-degree perineal laceration as evidenced by maternal report of discomfort, visible laceration, and guarding behaviors.” This diagnosis guides the care plan aimed at alleviating pain and promoting tissue healing. Additional diagnoses that may be considered include “Risk for infection related to perineal trauma and episiotomy” and “Impaired comfort related to tissue trauma and edema.”

Assessment Data

The mother reports pain characterized as a dull, throbbing sensation localized to the perineal area, rated 6 on a 10-point pain scale. Objective assessments reveal edema and erythema around the laceration, with mild bleeding or serous drainage. Her vital signs remain within normal limits. Physical examination confirms the presence of a second-degree tear extending through the subcutaneous tissue but not involving deeper structures. She demonstrates understanding of wound care instructions but expresses discomfort with mobility and sitting. Her lab data are unremarkable, and her medication regimen is adequate for pain management.

Patient Outcomes

  • Outcome 1: The mother will report a reduction in perineal pain to a score of 3 or less within 48 hours post-intervention, demonstrating effective pain control.
  • Outcome 2: The perineal wound will show signs of healing with minimal edema and no signs of infection (e.g., redness, warmth, purulent drainage) within 3 days of care initiation.

These outcomes are specific, measurable, and achievable within the short-term postpartum period, aligning with the mother’s needs and promoting comfort and tissue healing.

Interventions and Rationales

  1. Intervention: Administer prescribed analgesics (acetaminophen and ibuprofen) as scheduled. Rationale: These medications reduce inflammation and pain, facilitating mobility and comfort, which are essential for healing (Klose et al., 2018).
  2. Intervention: Teach mother proper perineal hygiene, including gentle cleansing with warm water after voiding and sitting in a sitz bath twice daily. Rationale: Proper hygiene promotes wound cleanliness and reduces infection risk, supporting optimal healing (Lowe et al., 2014).
  3. Intervention: Encourage mother to use ice packs on the perineal area for 20-minute intervals every 2 hours during the first 24 hours. Rationale: Ice reduces swelling, numbness, and pain, improving comfort and decreasing tissue inflammation (Herr et al., 2018).

For each intervention, the nurse ensures educational reinforcement and considers the mother's comfort and understanding, tailoring the interventions to her unique situation.

Evaluation

Following the interventions, the mother reports a pain level of 2 at 48 hours, indicating significant pain relief, thus meeting Outcome 1. Inspection reveals decreased edema and erythema; no signs of infection are observed, fulfilling Outcome 2. The plan of care is effective, and the mother demonstrates understanding of wound care, preparing her for continued recovery at home. If outcomes were unmet, further assessment and modification of interventions, including additional analgesics or wound assessments, would be warranted.

Conclusion

This postpartum care plan emphasizes individualized nursing actions grounded in evidence-based practices. By focusing on pain management, hygiene, and edema control, nurses can facilitate optimal healing and comfort for mothers experiencing perineal trauma. Continuous evaluation and patient education are vital to achieving desired health outcomes and promoting maternal confidence during recovery.

References

  • Herr, E. R., et al. (2018). Postpartum nursing care. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(3), 342–355.
  • Klose, P., et al. (2018). Pharmacological pain management postpartum. Pain Management Nursing, 19(4), 382–389.
  • Lowe, N. K., et al. (2014). Postpartum wound care and infection prevention. Nursing Clinics of North America, 49(4), 557–572.
  • Takacs, J., & McNeill, J. (2016). Maternal postpartum pain management practices. Journal of Perinatal & Neonatal Nursing, 30(3), 213–221.
  • American College of Obstetricians and Gynecologists. (2021). Postpartum care practice bulletin. Obstetrics & Gynecology, 138(3), e184–e199.
  • Carroll, J. et al. (2019). Managing episiotomy and perineal trauma. The Journal of Midwifery & Women’s Health, 64(4), 441–448.
  • Simkin, P., & Bolding, J. (2019). Nonpharmacologic pain relief methods in postpartum care. Journal of Obstetric, Gynecologic & Neonatal Nursing, 48(2), 130–140.
  • Wing, D. A., et al. (2020). Strategies to improve postpartum wound healing. Journal of Perinatal & Neonatal Nursing, 34(1), 11–20.
  • World Health Organization. (2018). Postpartum care guidelines. WHO Publications.
  • Wright, D., et al. (2022). Patient education and engagement in postpartum recovery. Nursing Outlook, 70(2), 192–201.

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