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;
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)
On Thursday September 21, 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 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 postpartum 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.
The following nursing diagnoses are to be used in this teaching plan:
Ø Risk for infection related to 2nd degree episiotomy.
Ø Knowledge deficit related to lack of knowledge about episiotomy.
Ø 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 postpartum period, she had been resting comfortable, but did have some pain. The pain was from her episiotomy, but with the help of pain medication it would soon diminish. She was attentive and communicated well with the nurses and she was able to ask questions concerning her care without any problems.
B) Motivation-K.C. showed much motivation to get out of bed. She was able to ambulate great without any signs of dizziness or loss of breath. In addition to her ambulating she seemed very enthused to learn about her episiotomy and perineum care.
C) Previous Knowledge-K.C. did lack previous knowledge of episiotomy. Her last two births this procedure was not needed. This did not stop her from learning now and she was willing to learn.
D) Experience-As stated before, K.C. has two other children. She did state that she does remember a little about perineum care. The episiotomy is the only new experience for her.
E) Cultural Factors-During my assessment of K.C., I asked if she has any religious preferences or practices that I should know about before teaching begins. She replied with a “nope”. I she sis stated that she did, I would have to do more research to her particular practice or belief.
K.C. said that she would like to have the learning experience in her room. Considering this is where is feels more comfortable. She had a single room and it was very quiet. Concluding that this was a good environment for learning to take place.
During my teaching time, I used pamphlets and advised her to keep them for future references.
Ø Define episiotomy and identify short and long term effects
Ø Identify self-care activities that will prevent infection
Ø Demonstrate the use of a peri-bottle, sitz bath and ice packs to promote comfort.
Ø Discuss the use of pain medications if needed
The teaching plan will focus on the care need for healing the episiotomy site, factors to prevent infection and the steps taken to promote comfort.
Nursing Diagnosis- Knowledge Deficit Related To Episiotomy
An episiotomy is a surgical incision that is made into the perineal body that is perceived by some physicians and certified nursing midwives to prevent damage to the periurethra, perineum, anal sphincter and rectum from lacerations during the birthing process (Lade & Olds, 1999). It is one of the most common procedures done during the time of labor and delivery. The purpose of this procedure is to prevent severe perineal tears from laceration or tearing further. Complications associated with an episiotomy are loss of blood, infection, pain and discomfort. Research has shown that the long-term effects are decreased pelvic floor muscle strength, sphincter injury and risk for urinary or fecal incontinence. The results of these effects can cause prolong pain, which will interfere with coitus. With the many long-term effects it is important to know about self-care measure. Self-care measures will help in the prevention of long-term effects from episiotomy.
Nursing Diagnosis-Risk For Infection Related To 2nd Degree Episiotomy
With the many degrees of episiotomies there is always the risk for infection. It is important for one to not contaminate the incisional site with bacteria from the rectal area. To prevent this from taking place, cleansing from front to back will prevent a bacteria infection. When washing the perineum area do not rub with washcloth always pat instead. This will prevent suturing from coming undone and will help with discomfort as well.
A peri-bottle will help provide comfort. Use after voiding and when ever comfort is needed. Best results occur when the bottle is filled with Luke warm water. The water should run down from perineal area to the anus. After use pat area dry with a washcloth or moist novelettes. Remembering to wipe from front to back. In addition, after using the peri-bottle it is always safe to change perineal pads, especially when there is a moderate amount of lochia (blood) present. The pad should fit snugly. A loosely worn pad will cause irritation from rubbing back and forth the perineum area. This to can cause a risk for infection.
Nursing Diagnosis- At Risk For Pain Related To Trauma T o Perineum, As Manifested By Client’s Request For Pain Medication
To help Relieve pain to perineum area, several comfort measures may be used;
Ø The use of ice packs. (20 minutes on and 10 minutes off)
Ø Sitz bath. Which can provide warmth, comfort and increasing circulation to the tissues that help promote healing. It is advised that 20 minutes in a tub filled 4-6 inches will suffice. Assessing water temperature before getting in. If a feeling of dizziness comes over, call the nurse. Sitz bath helps with pain relief only and should not be used as a tub bath.
Ø Topical agents (Dermoplast spray or American Spray) may be used to relieve discomfort.
Ø Pain medications as prescribed by physician may be administered to help provide comfort and decrease pain. Over the counter medications can also be taken, such as Tylenol or Motrin.
Evaluation-K.C. was able to define episiotomy and summarize about self-care needs to promote comfort and decrease the risk for infection. She was able to demonstrate the use of a peri-bottle, perineum care and she described the use of a sitz bath.
Strengths-The strength of the teaching plan was in the use of take home pamphlets. (As seen in appendix).
Areas of improvement-Taking more time in between each section of content to ask for any questions that she may have. Taking the opportunity to also make sure that she understands the content that was being discussed.
K.C. was given all props and pamphlets to take home for future needs. Fact sheets were given about the importance of Kegel exercises. These exercises as explained to her, but not covered under any of the nursing diagnosis, strength muscle control.
Johanson, R., (2000). Perineal massage for prevention of perineal trauma in childbirth. The Lancet. pgs: 335 and 250
Lade wig, P.A., London, M.L., Olds, S.B., (1999) Maternal-Newborn Nursing: A Family and Community Based Approach. New Jersey: Prentice Hall Health.