Teaching care plan for Perineal care postPartum Essay

This essay has a total of 2054 words and 11 pages.


Teaching care plan for Perineal care postPartum





Outline Title
Introduction:
I. Client Description
A. Nursing Diagnosis;
1. Knowledge deficit related to episiotomy.
2. Risk for infection related to 2nd degree episiotomy.
3. At risk for pain related to the trauma to perineum, as manifested by client’s request for pain medication.
B. Assessing the Readiness for Teaching;
1. Recovery from birth
2. Motivation
3. Previous knowledge
4. Experience
5. Cultural factors
II. The Content of Teaching Plan;
A. Nursing Diagnosis #1 (as stated under client description)
B. Nursing Diagnosis #2 (as stated under client description)
C. Nursing Diagnosis #3 (as stated under client description)
III. Assessment of Teaching Plan
IV. Conclusion
V. Appendix
VI. References Used


Teaching Plan for Perineal Care

Introduction:
On Thursday September 21, 2000, I care for a woman named K.C. Upon introducing myself to
K.C., she appeared to be relaxed and feeling comfortable. I had previously read her chart
before entering the room. On her charted it was noted that she had a 2nd degree
episiotomy done during labor and delivery

Before I began my assessment I asked her if she had any perineum pain. K.C. as quoted;
“I am feeling okay, but I do have a little pain and it is really not all that
bad.” My first response was to look on her medex for pain medications ordered.
Before doing so I asked her to rate her pain based on the pain scale (0-10, being 10 the
most awful pain that she has ever felt.. She said that she would have to rate her pain as
being a number 5. She had an order written for Motrin 8oomg every six hours for pain,
prn. I administered the pain medication. Afterwards K.C. asked a few questions in
regards to her episiotomy. She asked about short term and long-term effects on her.

I assured her that as her student nurse, I would try my best to explain the care she would
need related to her perineum area and her episiotomy. I really encourage her to be
straightforward with questions or concerns that she may have. Along with my teaching
plan, I referred her to the postpartum floor’s telephone number. If she thought of
any other questions that may arise when she goes home. I also told her not to be hesitant
and call her doctor if she feels that something is not right.




Client Description:
K.C. is a 33year old white woman, who does appear to be her stated age. She is a wife and
a mother of two other girls, not including the baby girl she just had. She is a high
school graduate and a stay at home mom. Her husband is the sole provider for the family.
She speaks highly about her two other children. The girls ages are 5 and 3. K.C. said
that she could not wait to bring the new baby home to meet her two girls. She explained
to me that she has been teaching them about their new sister, i.e. helping mommy change
her diapers, getting her dress and bathing her. I was quite surprise to hear that she was
teaching her daughters about caring for the new baby. This teaching is really going to
benefit her children and herself (she now has two little helpers).

It was mentioned that during her pre-natal visits, her daughters and her husband would
come to most visits. If her husbands schedule permitted. K.C. mentioned that her
physician was very helpful especially when she had questions. She said that her doctor
never hesitated when answering her and provided pamphlets to take home with her. This
really enabled her to have a good and positive outlook on the term of her pregnancy. She
said she has no complaints about her care and if her husband would let her she would do it
all over again.

K.C. described her labor and delivery as being really quick and painful, with a lot of
bleeding. She had a 2nd degree episiotomy done because of the tearing that might have
occurred otherwise pushing during delivery. In addition, because of the episiotomy there
was more bleeding than normal. Since this is her 3rd child, the intrapartum period only
lasted for 1 to 2 hours, which was quicker than her first two children.

K.C. described the beginning part of her post-partum course as tiring. She said that she
was really sore and was experiencing a lot of pain. She told me that she had a natural
birth with no pain medication during her labor. She said that she did this with all of
her births. Besides the soreness and pain she felt she had no other complaints. She was
enjoying her new healthy baby girl.

She had a normal vaginal delivery at 37 weeks gestation. Her baby’s agar scoring
was 9 and 10. K.C. said that her baby had blue fingers and toes (acrocyanosis) when she
was delivered, but it soon went away after her crying spell. She has decided to
breastfeed, and is able to see her baby within every 3-4 hour for feedings.


Nursing Diagnosis:
The following nursing diagnoses are to be used in this teaching plan:
Ř Risk for infection related to 2nd degree episiotomy.
Ř Knowledge deficit related to lack of knowledge about episiotomy.
Ř Pain related to trauma to perineum as manifested by client, requesting pain medication.
After assessing K.C., it was noted that she was at risk for the following nursing
diagnoses and that a teaching plan was needed. This opportunity helped me establish a
good nurse/client relationship. Know that we would both benefit from this experience.
Since I was feeling quite comfortable in this setting, I showed confidence to teach K.C.
all that I knew about her procedure. In return, she would be able to express her feeling
about the wellness of her growing family and concerns she had about the episiotomy.


Assessing the Readiness for Teaching:

A) Recovery from the birthing process- K.C. from the start of her post-partum period, she
had been resting comfortable, but did have some pain. The pain was from her episiotomy,
Continues for 6 more pages >>




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