Nursing Process Care Plan Format

Patient’s Initials: MP Case Presenting: M.Perez, a 31 year old female weighing 198 lbs.at 39 weeks of gestation with a history of 2
Student’s Name: Team # 1 miscarriages and 3 vaginal deliveries on 2013, 2014 & 2016. On admission assessment
Date: 07/08/20 G_7 T_3 P_0 A_4 L_3. NKA allergies. Medical Hx of Asthma, Genital herpes (Zovirx)
Patient is a Non-Smoker.

Assessment Nursing Diagnosis Planning Implementation Rationale Behind Evaluation

Intervention

Patient describes - Anxiety related to - Patient recognizes C- - Educate proper - May help in - Patient can display
lower middle perceived C-Section as section as an alternative relaxation techniques; decreasing anxiety timely healing of skin
abdominal constant a threat of maternal and childbirth procedure to position for comfort and tension, lesions/wounds
pain rated as 7 in a fetal well-being as as possible. Use promote comfort without complication.
achieve the best result
pain scale from 0–10. evidenced by increased possible in the end and therapeutic touch, as and enhance sense
tension. appropriate. of well-being. - The patient reports a
is at peace with this significant decrease
- teary eyed process.
- Give accurate - Decreases risk of on abdominal pain
- facial grimace - Acute pain related to rated as 3 in a scale
- irritable C-section incision as information in easy- skin contaminants
- Give analgesic as entering the from 0-10.
- skin warm to touch. evidenced by a to-understand terms
prescribed PRN for and clarify operative site,
guarding behavior, pain. - Patient is calm and
misconceptions. reducing risk of
Increased respiratory protecting the lower preoperative relaxed, with no signs
rate. midline abdomen. - Patient recognizes this of expressive
- Perform proper infection.
Increased tension and as an alternative behaviors such as
restlessness. wound care with restlessness.
- Risk for infection childbirth procedure to - Administering
sterile NS solution
related to exposure to achieve the best result pain medication
when removing - Patient has no signs
pathogens. possible in the end. prior stimuli will
dressings during of infection.
decrease pain
nursing shift.
level.
 - The nurse will - After nursing
provide analgesics intervention, patient
- Patient will describe a as ordered by verbalizes and
understand the C-
controlled reduction of physician after
Section procedure and
pain by the end of the assessing for pain postdelivery care.
shift. during nursing
shift.
- Patient is free from
UTI and wound
infection.

- Patient achieves timely

wound healing without
complications.