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DISCHARGE PLAN
Patients Name: B, S. M. B.

Hospital No:108583/15

Age: 20 years old

Room No: AW-13

Diagnosis: Normal Spontaneous Vaginal Delivery

Physician: Dr. M. L. V

PATIENTS OUTCOME CRITERIA

NURSING ORDER

As soon as the patient is discharge from

the hospital, the patient and the S.O will
be able to acquire basic knowledge,
develop skills and positive attitude in
caring for a patient suffering pain.
Specifically, they will be able to:

ASSESMENT
1. Discuss on how to assess the cause
pain.
A. Episiotomy

Discuss to the patient & S.O the

cause of pain.

A. Episiotomy is done as prophylaxis

against soft-tissue trauma. Vaginal
tears can occur during childbirth,
most often at the vaginal opening as
the babys head passes through,
especially if the baby descends
quickly.
2. Assess the patient vital signs

3. Assess factors affecting

interactions, nature of social
exchange and specifics of
individual behavior.

(Gulanick/Myers,2007;p. 145)
-

Teach the S.O of the patient on

how to take the vital
signs/obtaining the vital signs.

Discuss with the family the way

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4. Assess patient lochial discharge

signs and symptoms of
bleeding/infection.

of minimizing the concern and

care of the patient.
-

Advice patient to let the baby

suck for stimulating

PLANNING
1. Plan ahead the return visit to the
doctors clinic or hospital.

2. Make a chart or note the progress

of the pain.

3.

Make a chart or note to remind

them of a medication schedule.

4. Self Perineal Care

IMPLEMENTATION

-Remind the patient and the S.O to

follow the schedule when to come back
for the check-up for monitoring of the
status of the patient.
-Encourage the patient and the S.O for
making a chart to take down notes of
monitoring the progress of the pain.
-Remind the patient and the family to
take the time and take down notes
everytime they give medications to the
patient.
-Instruct the patient on family spacing &
for childbearing and childrearing.

1. MEDICATION
Comply the medication regimen.
2. EXERCISE
Encourage ambulation/exercise of the
patient as tolerated to promote circulation.

-Discuss them on how important to take

one medication.

-Encourage the patient to have an daily

exercise.

3. TREATMENT
Comply the patients regimen follow up,
check-up and dietary instruction.
4. HEALTH TEACHING
Do health teaching including patient and

- Explain to the patient on how important

treatment regimen is.

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the S.O to know her condition.

-Explain them the good teaching on how
to take good care or ourself.

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5. OUT-PATIENT REFERRAL
Plan for return visit.

-Remind the patient and the S.O aout

follow uo visit to the physician to
monitor the condition of the patient

6. DIET
Explain dietary regimen to follow.

-Encourage the patient to follow the

nutritious food pyramid
(Gulanick/Myers,2007;p. 146)

7. SPIRITUAL
Reflect, pray and read the bible
convenient.

-Encourage the patient to pray and read

the bible for spiritual healing

EVALUATION
1. Evaluate self-compliance of all
treatment regimen.

-Discuss to the patient and the S.O of

evaluating self-compliance in order to
monitor the condition of the patient.

2. Evaluate progress of the patient

health condition.

-Encourage the patient and S.O to

evaluate any progress of health
condition.

3. Accept patients condition

properly.

-Explore way in which significant others

can be supportive
(Doenges,2002; Maternal and Child
Nursing