- Acute Pain related to Tissue damage due to Cesarean delivery, Episiotomy repair and Engorgement as evidenced by Reports pain and intensity and Hot, swollen breasts
- Imbalanced Nutrition less than Body Requirements related to Postpartum depression and Insufficient food intake to meet metabolic demands as evidenced by food intake less than the recommended daily allowance and Inadequate breast milk production
- Ineffective Breastfeeding Related to Poor sucking reflex of infant as evidenced by
Expresses or observed difficulty in breastfeeding and Failure to latch
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbal reports from the patient Expressions of pain, such as crying Unpleasant feeling (such as a prick, burn, or ache) Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns | Acute Pain related to Tissue damage due to Cesarean delivery, Episiotomy repair and Engorgement as evidenced by Reports pain and intensity and Hot, swollen breasts | Patient will report reduced discomfort. Patient will demonstrate appropriate comfort measures to help alleviate pain. | 1. Administer medications as ordered. Pain medications like ibuprofen are given to help alleviate postpartum discomfort. Antibiotic therapy may also be indicated depending on the patient’s symptoms and if there is an infection present, such as mastitis. 2. Encourage the use of relaxation techniques for pain reduction. Relaxation techniques like deep breathing, massage, and meditation help alleviate discomfort and refocus the attention of postpartum patients. 3. Encourage early ambulation as tolerated. Early ambulation after childbirth promotes blood flow, speeds up tissue healing and recovery, reduces constipation and gas pain, and promotes pain relief. 4. Instruct when to use hot and cold therapies. Cold compresses are ideal for helping reduce pain and swelling in the perineal area. Warm compresses or a warm sitz bath promotes vasodilation, blood flow, and localized comfort. Utilize heating pads for back pain. 5. Encourage breastfeeding if there are no contraindications. Continuous breastfeeding can prevent breast discomfort due to engorgement and promote continuous breast milk production. If the patient is not able to breastfeed, instruct on how to use breast pumps. Both breasts must be emptied to prevent milk stasis, as this can increase the risk of breast abscess formation. 6. Encourage the patient to eat high-fiber foods. Perineal pain is common and can lead to constipation if the patient delays defecation for fear of pain. Intake of high-fiber foods, along with laxatives or stool softeners, can help decrease constipation and prevent straining when defecating. | Patient reported reduced discomfort. Patient will demonstrate appropriate comfort measures to help alleviate pain. |
| Subjective data: Verbalizes unable to eat more food Objective data: Constipation -Excessive hair loss -Hypoglycemia -Lethargy -Pale mucous membranes -Food intake less than the recommended daily allowance -Inadequate breast milk production -Poor wound healing | Imbalanced Nutrition less than Body Requirements related to Postpartum depression and Insufficient food intake to meet metabolic demands as evidenced by food intake less than the recommended daily allowance and Inadequate breast milk production | Patient will meet nutritional needs as evidenced by prompt postpartum recovery, timely wound healing, and appropriate energy levels. Patient will demonstrate adequate breast milk production. | 1. Discuss eating habits, food intolerances, and preferences. Postpartum patients need adequate nutrients to ensure prompt body recovery and wound healing, especially if a C-section was performed. Protein is vital for wound healing and recovery. Assess if the patient follows a particular diet like veganism that may require individualized interventions to meet nutritional needs. 2. Encourage vitamins or supplements as necessary. The patient may be recommended to continue prenatal or postnatal vitamins containing iron, iodine, and omega-3 fatty acids. 3. Encourage adequate rest periods. Most postpartum patients have less opportunity to rest and adapt to postpartum changes, compromising prompt recovery. Rest periods reduce metabolic rate and ensure nutrients are utilized for healing and energy. 4. Encourage adequate fluid intake. Adequate fluid intake in postpartum patients helps prevent dehydration and replenishes fluids to support breast milk production. 5. Refer the patient to a dietitian. A dietitian can help patients plan appropriate and well-balanced meals to meet individual needs during the postpartum phase. | Patient met nutritional needs as evidenced by prompt postpartum recovery, timely wound healing, and appropriate energy levels. Patient demonstrated adequate breast milk production. |
| Subjective data: Verbal reports from the patient related to poor breast feeding Objective data: -Expresses or observed difficulty in breastfeeding -Complaints of pain or nipple soreness -Insufficient emptying of breastmilk when feeding/inadequate milk supply -Infant displaying inadequate wet diapers or weight loss/inadequate weight gain -Failure to latch | Ineffective Breastfeeding Related to Poor sucking reflex of infant as evidenced by Expresses or observed difficulty in breastfeeding and Failure to latch | Mother will implement two techniques to improve breastfeeding. Infant will display effective breastfeeding as evidenced by appropriate weight gain. | 1. Provide 1:1 support. Breastfeeding for new mothers may take time and practice. Allow 1:1 time with emotional support. Sessions can be 30 minutes or longer in the beginning. 2. Teach to recognize cues. Educate the mother on early cues from the infant. Rooting, lip-smacking, and sucking fingers/hands signal a desire to eat. Recognizing cues for timely feeding promotes a better experience for mom and baby. 3. Prevent and treat breastfeeding complications. If ineffective breastfeeding is related to nipple pain or engorgement, intervene accordingly. Heat or cool application and massage can ease engorgement. Apply lanolin to nipples and do not use harsh soaps. Use cotton bras or pads. 4. Coordinate with a lactation consultant. Lactation consultants help instruct on breastfeeding positions, feeding schedules, increasing the milk supply, and using a breast pump. | Mother implemented two techniques to improve breastfeeding. Infant will display effective breastfeeding as evidenced by appropriate weight gain. |