Teaching Care Plan for Perineal Care
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
3. Previous knowledge
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
VI. References Used
Teaching Plan for Perineal Care
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.
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...