Postnasal Nursing Care Nursing Diagnosis and Intervention

Nursing Diagnosis and Intervention Pain (acute)/discomfort related to mechanical trauma. 1) Assess the presence, location, nature and degree of discomfort/pain. R: Identifying special needs and appropriate interventions 2) Inspection of perineal repair and episiotomy. R: May indicate excessive trauma and/or complications. 3) Teach relaxation techniques (ice/hot compresses, deep breathing) and distraction techniques (doing activities/distractions) on the perineum.R: Increases vasoconstriction, circulation, oxygenation and nutrition in the perineal tissue and reduces edema and vasodilation. 4) Assess uterine tenderness: determine the presence and frequency/intensity of afterpain as well as aggravating factors (multipara, uterine overdistension, breastfeeding, oxytocin).R: During the first 12 hours postpartum, uterine contractions are strong and regular and this continues for the next 2-3 days. 5) Encourage the client to start breastfeeding on the nipple that is not painful sequentially. R: The initial sucking response is strong and may cause pain. 6) Assess the client for bladder fullness. Encourage you to urinate immediately when you feel full. R: Bladder overdistension can create feelings of discomfort. 7) Give analgesics as indicated.R: Reduces pain and provides comfort.R:High risk of infection related to tissue trauma 8) Monitor temperature and pulse regularly and according to indications.R: Increase in temperature to 38.3oC in the first 24 hours is highly indicative of infection. 9) Assess the location and contractility of the uterus. Note involutional changes and the presence of extreme uterine tenderness.R: The occurrence of extreme tenderness, indicating the possibility of retained placental tissue / infection. 10) Note the characteristics (amount, color, odor, consistency) of the loccheal discharge. R: Normal Lochea has a fishy/meaty odor. If the smell is foul and purulent suspect infection. 11) Assess the episiotomy repair site every 8 hours. Note excessive tenderness, redness, purulent exudate, edema, febrile.R: Early diagnosis of local infection can prevent spread to uterine tissue. 12) Recommend perineal care by changing sanitary napkins every 4 hours from front to back.R: Prevent rectal contamination from entering the vagina / urethra. 13) Encourage clients to eat foods high in protein, vitamin C and iron. R: Protein helps increase healing and regeneration of new tissue, iron for hemoglobin synthesis, vitamin C for iron absorption and cell wall synthesis. 14) Provide episiotomy wound care. R: Prevent infection. 15) Give antibiotics as indicated.R: Prevent infection from spreading to surrounding tissue or bloodstream. Potential for effective breastfeeding 1) Assess the client's previous knowledge and experience of breastfeeding.R: Helps in identifying current needs. 2) Provide verbal and written information regarding the physiology and benefits of breastfeeding, nipple and breast care, special dietary requirements and factors that facilitate or interfere with successful breastfeeding.R: Written information can provide a source that clients can refer to as needed. 3) Instruct the client to dry the nipple with air 20-30 seconds after breastfeedingR: Increases mother's comfort and prevents cracked nipples 4) Assess the nipples and milk productionR: Identifying the adequacy of breast milk production 5) Identify sources available in the community according to indicationsR: Increase independence and provide support for adaptation to multiple changes. High risk of injury associated with biochemistry, regulatory function, thromboembolism, abnormal blood profile 1) Review Hb levels and blood loss during labor. R: Anemia and heavy bleeding during labor increase the risk of injury to the client. 2) Encourage early ambulation except in patients receiving subarachnoid anesthesiaR: Prevent thromboembolism and improve blood circulation. 3) Encourage lying in a flat position if dizzyR: Increases comfort. 4) Inspect for signs of thrombophlebitis in the lower extremities.R: Indicates circulation problems to distal organs. 5) Give anticoagulants.R: Prevent further thrombus Changes in urine elimination 1) Assess fluid intake and outputR: Small amounts of urination and frequent urination in succession indicate a urinary disorder. 2) Palpate the bladder, monitor TFU and the amount of locheal flow R: A round and soft bladder indicates that a lot of urine is being stored. 3) Assess for signs of UTI R: Identifying urinary tract disorders. 4) Instruct to do Kegel exercises every day after the anesthetic effect wears off R: Stimulates the nerves and pelvic muscles to urinate. 5) Carry out catheterization if necessary and obtain a urine specimen. R: Remove urine for laboratory examination.