Pamantasan ng Lungsod ng Marikina College of Nursing Marikina City ______________________________________________ In Partial Fulfillment of the Course Requirements in Care of Care of Mother, Child, Adolescent (Well Client) Related Learning Experience ____________________________________________________ Presented by: Sophia Anne A. Zerna Section: 2BSN5 | Group no. 22 I. Patient Data A. Personal Data Name: Reijen Godalle Absalon Sex: Female Age: 18 YO Address: Marital Status: Single Occupation: Unemployed GTPAL: G1P0 (Primigravida) LMP: 9/29/23 (September 29, 2023) Age of Gestation: 14 2/7 (14 weeks and 2 days) EDD: 7/5/24 (July 5, 2024) EDC: 6/15/24 (June 15, 2024) B. Chief Complaint: Episiotomy pain post-delivery Raiza, a 32-year-old woman, presented postpartum, expressing discomfort and pain associated with her recent episiotomy. She described persistent pain in the perineal area following the childbirth procedure. Examination revealed signs of healing and inflammation around the episiotomy site. Given the recent delivery and the nature of the complaint, measures were taken to address her discomfort, including tailored pain management strategies for postpartum care and appropriate wound care instructions. Counseling was provided to Raiza regarding the expected healing process and recommendations for follow-up care to ensure proper recovery from the episiotomy. C. Nursing Health History 1. Present Illness The patient's current health concern revolves around postpartum recovery following a recent childbirth, particularly discomfort and pain associated with a recent episiotomy. Notably, there is an increased susceptibility to infection in the perineal area surrounding the episiotomy site. Examination reveals signs of healing and inflammation at the incision site, raising concerns about potential infection risks. 2. Past Illness The patient's past health history is notably unremarkable for any significant illnesses or chronic medical conditions. There are no documented instances of major medical concerns, chronic diseases, or ongoing health issues in her medical records. She has not reported any prior hospitalizations or surgeries related to specific illnesses. Overall, the patient's past health history indicates a generally healthy status without significant medical conditions or noteworthy illnesses. 3. Family History of Illness The patient's family health history does not reveal any significant illnesses or hereditary conditions among immediate family members. There are no documented instances of major genetic disorders, chronic diseases, or significant medical conditions present in her family history. Additionally, there are no reports of familial predispositions to specific illnesses or health concerns that could impact the patient's current health status. Overall, the patient's family health history suggests an absence of notable illnesses or hereditary conditions among close relatives. 4. Social History The patient reports a non-smoking and non-drinking lifestyle, adhering to healthy habits by engaging in regular exercise primarily through walking. She expresses significant stress and fatigue due to the responsibilities of caring for five children. Despite these stressors, there are no reported exposures to violence or unsafe environments in her daily life. The patient's focus on physical activity through walking serves as her primary form of exercise, while the challenges associated with caregiving for her five children contribute to considerable stress and fatigue levels. There are no reported instances of exposure to violent or unsafe situations in her living environment. 5. Gordon’s HEALTH PERCEPTION/HEALTH MANAGEMENT How would you describe your usual health status? The patient stated that she generally maintains good health by consistently consuming healthy foods. Are you satisfied with your usual health status? Yes Tobacco use? Number of packs per day? None Alcohol use? How much and what kind? None Street drugs? What and how much? None Any history of chronic disease? Describe. None Immunization History? Complete Have you sought any healthcare assistance in the past year? Why? Prenatal Checkups Current work & how would you rate your working conditions? Housewife How would you rate living conditions at home? The patient affirmed that she has access to essentials such as food, clean water, shelter, sanitation, warmth, and utilities, which are integral for ensuring secure and comfortable living conditions Do you have any difficulty securing any of the No following services? Medications (over-the-counter & prescription) Yes Have you followed the routine prescribed for you? Have you had any accidents/injuries/falls in the past? Describe. No Have you had any problems with cuts healing? The patient specifically notes that she is currently experiencing problems with the healing of the cuts from the episiotomy, which have arisen only recently. Do you exercise regularly? Type & Frequency? Walking daily Do you have any suggestions or requests for None improving your health? Describe. Do you do (breast/testicular) self-examination? How often? No The patient mentions that she experienced weight gain NUTRITIONAL - METABOLIC during her pregnancy but is uncertain about the exact Any weight gain & gain in the last 6 months? amount of weight she gained. How many? How would you describe your appetite? The patient describes her eating habits as consuming regular portion sizes three times a day. Do you have any food intolerance/restrictions?Describe. None Describe an average day's food intake for you 3 meals a day (meals/snacks). Describe an average day's fluid intake for More than 8 glasses a day you. Describe food likes and dislikes. Salty foods Would you like to gain or lose weight? The patient expresses her desire to shed the extra weight and work on toning her body. Any problems with Nausea, vomiting, swallowing, chewing, indigestion None How would you describe your usual lifestyle? The patient expresses that her lifestyle aligns with the typical routine of a housewife. For breastfeeding mothers only: Do you have None concerns about breastfeeding? Describe. ELIMINATION PATTERN What is your usual frequency of bowel movements? Once a day Character of Stool: (character, color, and bleeding) Normal History of constipation (usage of bowel movement aids) None History of diarrhea None History of incontinence None Usual voiding pattern: frequency, awareness/urge to void, amount, color, incontinence None ACTIVITY-EXERCISE PATTERN How does the client perceive her/his self-care Walking activities? How many pillows do you use to sleep on? One Do you experience fatigue/ weakness? Describe. She mentions experiencing fatigue particularly after busy and hectic days. Occupation Housewife Describe your usual leisure time activities/hobbies She mentions that she spends her leisure time watching Netflix. Any problems with concentration? Describe. SLEEP REST PATTERN Usual sleep habits? Describe. None She indicates that she typically gets 5-6 hours of sleep at night and compensates by taking afternoon naps. Problems: difficulty going to sleep? Awakening at night, early awakening? Insomnia? None Methods used to promote sleep: medication, warm fluids, techniques None COGNITIVE-PERCEPTUAL PATTERN Pain: PQRST P- “The pain usually gets worse when I move around, especially when I'm trying to sit down or stand up from a seated position (Provocation). Applying an ice pack seems to help relieve it temporarily (Palliation).” Q- “It's more like a sharp, stabbing sensation, especially when I'm walking or changing positions (Quality).” R- "The pain is mainly centered around the episiotomy site, but sometimes it radiates to my lower abdomen and thighs (Region/Radiation)." S-"I'd rate it around a 6 or 7. It's pretty uncomfortable and affects my daily activities (Severity).” T-"The pain started a few days after delivery, and it's been persistent since then. It's there most of the time, but it tends to increase when I'm more active or trying to sit for extended periods (Timing)." Perception of decision making? Easily makes decision Knowledge level: current problems, restate current therapeutic regimen None SELF-PERCEPTION AND SELF-CONCEPT PATTERN None What is your major concern at the current time? Do you think this admission will cause any lifestyle and result in any body changes for you? No What is your visual of yourself? Normal Do you believe you will have any problems dealing with your current health situation? Describe The patient acknowledges that experiencing some level of pain from the episiotomy is expected during the recovery process. However, she emphasizes her readiness to seek medical advice promptly if there are any concerning developments or if the pain worsens. She is aware of the importance of adhering to her doctor's instructions and will follow their guidance for managing and monitoring the healing process of her episiotomy wound. On a scale of 0-5 rank your perception of your level of control in this situation 4 On a scale of 0-5 rank your usual assertiveness level. 5 ROLE-RELATIONSHIP PATTERN Status of your patient. If married, rate your parenting skills. The patient evaluates her parenting skills as generally good. However, she acknowledges that at times, she finds it necessary to scold her children. This occurs particularly when they struggle with managing their time and belongings, indicating a need for guidance or discipline in these areas. Any losses: physical, psychological, or social in the past year? No How is the patient handling this loss at this time? None Do you believe this admission will result in any type of loss? No Do you think this admission will cause changes in family roles? No How would you rate your usual social activities? 4 How would you rate your comfort in social situations? 4 What activities or jobs do you like and dislike to do?Describe. The patient expresses a fondness for her daily walks and enjoys sharing meals with her family. However, she admits a dislike for the task of folding clothes. SEXUALITY-REPRODUCTIVE PATTERN Female: LMP, Pregnancy, Menopause? Birth Control Measures, history of vaginal discharge, bleeding, lesions, pap smear, sexually transmitted disease. Male: prostate problems, penile discharge, bleeding, lesions, sexually transmitted disease GTPAL: G6P6(6006) Bilateral Tubal Ligation None Both: problems in sexual functioning, and sexual relationships, Describe. None Do you believe this admission will have any impact on sexual functioning? Describe. No COPING-STRESS TOLERANCE PATTERN Have you experienced any stressful or traumatic events? The patient communicates that her primary source of stress stems from the responsibilities associated with her role as a housewife. How would you rate your usual handling of stress? The patient rates herself as adept at managing stress and endeavors to prevent its impact from affecting her family, attempting not to direct her stress toward them. What is the primary way you deal with stress or problems? She copes with stress by openly communicating with her husband and children about her feelings. Have you used any counseling groups in the past year? No What do you believe is the primary reason behind this admission? Pregnancy Do you seek health assistance at the first symptom? N/A Are you satisfied with the care you have been Yes receiving? VALUE-BELIEF PATTERN Are you satisfied with the way your life has been developing? Yes Will this admission interfere with your plans for the future? No Religion? Any religious restrictions to care? N/A Will this admission interfere with your spiritual or religious practices? No Have your religious beliefs helped you to deal N/A with problems in the past? D. Obstetrical History The patient's obstetric history is recorded as G6P6 (6006), indicating she has been pregnant six times, given birth to six children, all of whom were delivered through spontaneous normal deliveries. E. Physical Assessment 1. Head to Toe Assessment ● Head - Normocephalic (normal head shape and size), atraumatic (no signs of injury) - Symmetric facial features, no abnormalities noted - Eyes: Pupils equally round and reactive to light, visual acuity intact, normal eye movements -Ears: Bilateral ears symmetrical, intact, no discharge or inflammation -Nose: Nasal septum midline, no signs of congestion or discharge -Mouth: Oral mucosa pink and moist, intact teeth, no lesions, or cavities, clear speech ● Neck -Supple neck movements, full range of motion without tenderness or masses -No lymphadenopathy (enlarged lymph nodes), thyroid gland non-palpable ● Chest and Lungs -Chest symmetrical, no deformities or abnormalities -Respirations regular, lungs clear to auscultation bilaterally, no adventitious sounds (such as crackles or wheezes) ● Cardiovascular -Chest symmetrical, no deformities or abnormalities -Respirations regular, lungs clear to auscultation bilaterally, no adventitious sounds (such as crackles or wheezes) ● Abdomen -Abdomen soft, non-tender, no distension, masses, or organomegaly -Bowel sounds present in all quadrants ● Musculoskeletal -Normal muscle tone and strength in all extremities -Full range of motion in major joints without pain or swelling ● Skin -Skin warm, dry, and intact without lesions, rashes, or bruising -No signs of edema in the extremities ● Neurological -Alert and oriented to person, place, and time -Cranial nerves intact, no focal neurological deficits -Coordination and balance normal 2. Bubble She Assessment ● B - Breasts: Bilateral breasts are soft, non-tender, and without signs of engorgement or redness. No palpable masses or lumps noted. ● U - Uterus: Uterus is palpable at or near the umbilicus, firm, and contracting appropriately (involution is progressing as expected). ● B - Bowel: Patient reports regular bowel movements without signs of constipation or abdominal discomfort. No distension or abnormal bowel sounds noted. ● B - Bladder: The patient experiences pain during urination but denies urgency, frequency, or difficulty in passing urine. No signs of urinary retention or incontinence observed. ● L - Lochia: Lochia is present, with the patient using 3 pads in one day, indicating a moderate amount of bleeding. The discharge is serosanguinous or lighter in color and without foul odor. ● E - Episiotomy: The patient reports discomfort and pain at the episiotomy site during daily activities. No signs of infection, excessive redness, or discharge are observed. Normal healing process appears to be ongoing, albeit with discomfort. ● H - Homan's Sign: No tenderness or pain on palpation of the calf muscles. No signs of deep vein thrombosis (DVT). ● E - Emotional State: Patient appears emotionally stable, expresses happiness about her newborn, and denies feelings of depression or excessive anxiety. Displays appropriate bonding and interaction with the infant. F. Laboratory Results The patient's laboratory results have returned within normal ranges, indicating a favorable postpartum recovery. These results provide reassurance regarding her overall health status and the absence of any concerning abnormalities. The normal findings across various lab parameters, including blood tests, urine analysis, and other relevant tests, suggest that her body is recuperating well following childbirth. Given the normal laboratory results and the absence of any complications, the patient demonstrates a positive trajectory in her postpartum recovery. Her readiness for discharge aligns with her favorable clinical condition, highlighting a successful transition to the postpartum phase. It's imperative to emphasize the significance of continued post-discharge care, including adequate rest, proper wound care, monitoring of Lochial discharge, pain management, and emotional support. These measures aim to ensure a smooth and uneventful recovery as she transitions back home and adjusts to the demands of caring for her newborn. In conclusion, the patient's normal laboratory findings indicate a favorable recovery, enabling her readiness for discharge. However, ongoing support and guidance post-discharge are crucial to promote her well-being during this postpartum period. II. Planning 1. List of priorities Nsg.Diagnosis (3) Rank/Dx.statement/Cues/Justification 01. Acute Pain related to episiotomy Rank/Dx. Statement: Acute Pain related to episiotomy as evidenced by patient reports of discomfort and pain at the episiotomy site during daily activities. Cues/Justification: Patient verbalizes discomfort and pain at the site of the episiotomy, affecting her ability to perform daily tasks. Pain is a direct result of the recent episiotomy procedure. 02. Risk for Infection Rank/Dx. Statement: Risk for Infection as evidenced by pain during urination. Cues/Justification: Patient reports pain during urination, which is an indicator of possible infection or inflammation. Pain while urinating can be an early sign of a urinary tract infection (UTI) or another infection related to the perineal area. 03. Deficient Knowledge regarding condition, treatment, prognosis, self-care, and discharge needs Rank/Dx. Statement: Deficient Knowledge regarding condition, treatment, prognosis, self-care, and discharge needs as evidenced by lack of understanding or confusion about the condition. Cues/Justification: Patient demonstrates a lack of understanding or confusion regarding postpartum care, including wound healing, self-care, and expectations after discharge. The patient's uncertainty indicates a need for further education and clarification on postpartum care and discharge instructions. 2. Nursing Care Plan III. Implementation A. Medical Management The healthcare provider has prescribed mefenamic acid to aid in managing the discomfort associated with the episiotomy wound during the patient's postpartum recovery. The patient has confirmed no known allergies or adverse reactions to this medication, ensuring a safe and appropriate choice for pain relief in this specific situation. With this prescription, the aim is to alleviate the patient's pain while closely monitoring for any potential side effects or complications. B. Nursing Management 01. Pain Management: ● Provide regular assessment of pain intensity and administer prescribed pain medications as needed. ● Encourage the use of comfort measures such as ice packs or sitz baths to alleviate discomfort at the episiotomy site. ● Educate the patient on proper positioning and movement techniques to minimize pain during activities. 02. Wound Care: ● Instruct the patient on proper perineal hygiene, including gentle cleaning with water after using the toilet and changing pads frequently. ● Monitor the episiotomy site for signs of infection or delayed healing and report any abnormalities to the healthcare provider. 03. Education and Support: ● Provide comprehensive education about postpartum care, including explanations about Lochia, perineal care, signs of infection, and activities to avoid. ● Offer emotional support, listening attentively to concerns, and addressing any anxieties or questions the patient may have about the postpartum period. 04. Mobility and Activity: ● Encourage gentle mobility and ambulation to prevent blood clots and promote circulation, while advising to avoid strenuous activities. ● Emphasize the importance of rest and adequate sleep to support the healing process. 05. Nutrition and Hydration: ● Ensure the patient maintains a balanced diet rich in nutrients and encourages hydration to support healing and overall health. 06. Follow-up Care and Support: ● Arrange follow-up appointments with healthcare providers for assessment of wound healing and to address any ongoing concerns. ● Provide contact information for healthcare professionals in case of questions or emergent issues post-discharge. 07. Family Support and Education: ● Involve family members in the patient's care plan, educating them on how to provide support and assist the patient during the postpartum recovery period. C. Daily Progress Chart 1. Drug Study Medication Name: Mefenamic Acid Therapeutic Class: Nonsteroidal Anti-Inflammatory Drug (NSAID) Indication: Pain relief associated with the episiotomy wound post-childbirth Mechanism of Action: Mefenamic acid works by inhibiting the production of prostaglandins, which are substances in the body that cause pain and inflammation. By reducing prostaglandin levels, it helps alleviate pain, swelling, and discomfort. Dosage and Administration: The typical dosage for mefenamic acid is usually prescribed as directed by the healthcare provider. It's commonly taken orally with a full glass of water, usually after meals or with food to minimize stomach upset. The patient should strictly adhere to the prescribed dosage and frequency. Monitoring and Considerations: Pain Management: Mefenamic acid is effective in managing moderate to severe pain, such as that associated with the episiotomy wound. Regular assessment of pain intensity and relief should be conducted to ensure adequate pain control . Adverse Effects: NSAIDs, including mefenamic acid, may cause side effects such as gastrointestinal irritation, stomach ulcers, and increased risk of bleeding. The patient should promptly report any signs of abdominal pain, black stools, or blood in the urine. Contraindications and Precautions: Patients with a history of gastrointestinal ulcers, bleeding disorders, kidney problems, or allergic reactions to NSAIDs should avoid mefenamic acid. It should be used cautiously in patients with underlying conditions or those taking other medications that may interact with NSAIDs. Duration of Use: Mefenamic acid is usually prescribed for a short duration to manage acute pain. Prolonged use should be avoided unless specifically directed by the healthcare provider. Patient Education and Counseling: The patient should be educated about the proper use of mefenamic acid, including dosage, timing, and potential side effects. Emphasize the importance of taking medication with food to reduce the risk of stomach irritation. Instruct the patient to follow up with the healthcare provider if the pain persists or if they experience any concerning side effects. 2. Treatment The treatment plan for the patient following an episiotomy involves pain management using prescribed medications like acetaminophen or NSAIDs, along with proper wound care techniques including gentle hygiene, sitz baths, and potential topical treatments. Preventative measures against infection include monitoring for signs of infection and, if needed, the use of antibiotics. To aid healing, adequate rest, a balanced diet, and hydration are emphasized. Follow-up appointments for postpartum check-ups ensure monitoring of healing progress and any necessary further care. Patient education is crucial, encompassing detailed instructions on postpartum care and when to seek medical attention for complications or concerns. 3. Diet Following a normal spontaneous delivery, the mother benefited from a balanced and nutritious diet crucial for her postpartum recovery. A variety of nutrient-rich foods, including fruits, vegetables, whole grains, lean proteins (such as poultry, fish, beans), and healthy fats (like nuts, seeds, and avocados), were emphasized. Adequate hydration, primarily through water intake, supported her overall recovery. Protein sources like lean meats, fish, eggs, legumes, and tofu were prioritized for their role in tissue repair and immune support. Fiber-rich foods such as whole grains, fruits, and vegetables helped prevent constipation. Iron-rich foods like lean red meat, leafy greens, and fortified cereals aided in replenishing iron stores post-blood loss during childbirth. Additionally, calcium sources such as dairy products, fortified plant-based milk, and leafy greens promoted bone health. She limited processed foods and added sugars while opting for healthy snacks like yogurt, nuts, and fruits to maintain energy levels between meals. Consulting with a healthcare professional or a registered dietitian for personalized dietary advice or considerations related to breastfeeding or specific health conditions was recommended. Ultimately, this well-rounded diet supported her postpartum recovery and provided essential nutrients for both her and her baby's well-being. 4. Activity/Exercise After giving birth, the initial recommended activities and exercises were gentle and focused on aiding the postpartum recovery process. These included light walks in the immediate postpartum period, starting with short and slow walks to improve circulation and gradually increase activity levels. Deep breathing, relaxation techniques, and gentle stretching were suggested to promote relaxation and flexibility. It's important to note that healthcare providers generally advise a gradual approach to exercises like Kegels, abdominal exercises, or more strenuous activities, encouraging women to wait until they've sufficiently healed before attempting these exercises. Consulting with healthcare providers for personalized guidance on the appropriate timing and types of exercises was recommended to ensure a safe and effective postpartum recovery IV. Evaluation A. Narrative Evaluation of Actual Nursing Problem The patient, a 32-year-old woman who underwent a spontaneous vaginal delivery, presented with complaints of discomfort and pain localized at the episiotomy site. Upon assessment, she expressed tenderness and reported difficulty in performing daily activities due to the pain intensity, scoring it at 7 out of 10 on the pain scale. Assessment revealed redness and swelling around the episiotomy wound, indicating a need for immediate pain management and wound care. Nursing interventions were promptly initiated to address the acute pain and support the patient's recovery. Pain management strategies included the administration of prescribed analgesics, such as mefenamic acid, to alleviate pain, as well as the application of ice packs to the perineal area for comfort. Additionally, the patient was educated on the importance of proper perineal hygiene, including gentle cleaning techniques, and advised on the use of sitz baths to reduce discomfort and promote healing. Regular assessments were conducted to monitor the effectiveness of pain relief interventions and wound healing progress. Subsequent evaluations revealed a gradual decrease in pain intensity from 7 to 4 out of 10 on the pain scale over a span of five days. The episiotomy site exhibited signs of healing, with reduced redness and swelling, indicative of a positive response to the implemented nursing interventions. In collaboration with the healthcare team, the patient was discharged with comprehensive instructions for continued wound care and pain management at home. She was advised to continue prescribed medications as directed and maintain proper hygiene practices. Follow-up appointments were scheduled to monitor further healing progress and address any concerns. The nursing care plan focused on effectively managing acute pain related to the episiotomy, employing a multidisciplinary approach that encompassed pharmacological interventions, wound care, patient education, and continuous assessment. The interventions aimed not only to alleviate pain but also to support optimal healing and enhance the patient's comfort during the postpartum period. B. Discharge Planning Instructions (Methods) Discharge Planning Instructions: Post-Episiotomy Care ● ● ● ● ● ● ● Wound Care Instructions: ○ Perineal Hygiene: Maintain proper perineal hygiene by gently washing the area with warm water after using the toilet. Pat dry gently with a clean towel. ○ Sitz Baths: Take sitz baths (sitting in warm water) several times a day to aid in healing and reduce discomfort. Pat dry afterward. Pain Management: ○ Medications: Continue taking prescribed pain medications (if any) as directed by your healthcare provider to manage discomfort. Take them with food to avoid stomach upset. ○ Use of Ice Packs: Apply ice packs to the perineal area as needed for pain relief. Ensure they are wrapped in a cloth to prevent direct contact with the skin. Activity and Rest: ○ Avoid Strenuous Activities: Refrain from heavy lifting, intense exercise, or any activity that puts pressure on the perineum until cleared by your healthcare provider. ○ Rest: Allow yourself adequate rest periods throughout the day to support healing and recovery. Follow-up Care: ○ Scheduled Appointments: Attend follow-up appointments as scheduled with your healthcare provider to monitor healing progress and address any concerns. ○ Contact Information: Keep contact details of your healthcare provider readily available for any questions or emergent issues. Diet and Hydration: ○ Nutritious Diet: Maintain a balanced diet with plenty of fruits, vegetables, whole grains, and protein sources to support healing. ○ Hydration: Ensure adequate fluid intake, primarily water, to stay hydrated. Signs of Complications: ○ Watch for Signs of Infection: Be vigilant for any signs of infection such as increased redness, swelling, warmth, or abnormal discharge from the episiotomy site. Contact your healthcare provider if you notice any concerning changes. Breastfeeding Support (If Applicable): ○ Breast Care: If breastfeeding, continue with good breast care techniques, and consult a lactation specialist or healthcare provider for any breastfeeding-related concerns. References: Delaune, S. C., & Ladner, P. K. (2002). Fundamentals of Nursing: Standards & Practice (2nd ed.). Thomson Learning. Doenges, M., Moorhouse, M. F., & Murr, A. C. (2014). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Lifespan. F.A. Davis Company. Jones, & Bartlett Learning. (2011). Nurse's Drug Handbook. Jones & Bartlett Learning.
