The patient delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration
Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this patient? 1. Assist the patient to the bathroom in 2 hours to void.
2. Place a Foley catheter now.
3. Apply warm packs to the perineum three times a day.
4. Allow the patient to rest for the next 8 hours.
1
Rationale 1: This patient is at risk for urinary retention and bladder overdistention from both the perineal edema and the effects of the epidural. Assisting the patient to the bathroom is the most likely intervention that will prevent urinary retention. If the patient is unable to void soon, a straight in-and-out catheter may be used.
Rationale 2: A Foley catheter is not indicated at this time.
Rationale 3: Cold packs will help decrease the perineal edema; warm packs would increase the edema.
Rationale 4: Waiting 8 hours to reassess the bladder is too long.
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