ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION
SUBJECTIVE: Risk for infection Contamination of a Long Term: Independent: Long Term:
related to presence of wound surface with After two days of  Change perineal  To prevent After two days of
No Verbalization surgical wounds as microorganism thus interventions the pads frequently. vaginal interventions the
evidenced by MER these colonization client will be able to contamination or client was able to
2nd degree has a complete new free from infection. infection. free from infection.
OBJECTIVE: cells for oxygen and
nutrition and because Short Term:  Perform perineal  To promote Short Term:
 Presence of their by-products can After two hours of care cleanliness to the After two hours of
perineal wounds interfere with a interventions the perineal area interventions the
due to healthy surface client will be able to: client was able to:
episiotomy condition that leads  Verbalize Health  Warm  To avoid edema  Verbalize Health
second degree to infection Teachings compressed may Teachings
 Not practicing be applied to the
frequent -Fundamentals of  Demonstrate at genital area  Demonstrate at
changing of Nursing by Kozier least 3 ways on least 3 ways on
pads page 910 how to prevent Collaborative: how to prevent
infection.  Sitz bath may be  To aid healing of infection.
ordered the perineum
thorough
application of
moist heat

NURSING CARE PLAN

 Nursing Diagnosis Rank Justification

Pain related to damage on It is highly prioritized because based

muscle tissue as evidenced by 1 on the Maslow’s Hierarchy of Needs
episiotomy MER 2nd degree the physiologic needs of the patient is
greatly affected and need an
immediate action.

Constipation related to It is second prioritized problem

irregular defecation as 2 because based on the Maslow’s
evidenced by not defecating Hierarchy of Needs the physiologic
for 4-5 days. needs of the patient is affected and
need an immediate action.

Risk for infection related to It is third prioritized because based on

presence of surgical wounds 3 the Types of Nursing Diagnosis the
as evidenced by MER 2nd patient’s health is at “risk” and may
degree. likely happen.

Risk for falls related to It is fourth prioritized because based

absence of side rails 4 on the Types of Nursing Diagnosis the
secondary to not being raised. patient’s health is at “risk” and may
likely happen.

Health seeking behavior It is least prioritized because based on

related to precipitating 5 the Types of Nursing Diagnosis the
concern about the current patient’s health is at wellness state
health status as evidenced by
hospitalization

LIST OF PRIORIIZED PROBLEM