SY 2019-2020

COLLEGE OF NURSING
Silliman University
Dumaguete City

NURSING CARE PLAN

Submitted by:
Barazan, Riza Angela A.
Estolloso, Francis Robert U.
Pileo, Kristine Jamille R.

Submitted to:
Dr. Maria Theresa C. Belciña Jr.
 NURSING
CUES/EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: Impaired skin integrity At the end of our care, Independent: At the end of our care,
related to fourth degree patient will be able to: patient was able to:
Client verbalized that laceration in the perineal Assess the To obtain baseline data.
characteristics of the
she had a very long area secondary to Demonstrate GOAL MET.
wound, including color,
delivery and there is episiotomy wound understanding and size, amount, and odor. Demonstrated self-care
stinging pain in her importance of self-care activities and understood
perineal area. activities. Inspect the wound every Frequent assessment can the importance of doing
shift using the REEDA detect signs and so.
Client verbalized that Display timely healing (redness, edema, symptoms of possible
her episiotomy wound of skin wounds without ecchymosis, discharge, infection. GOAL PARTIALLY
and approximation) MET. Showed signs of
appears swollen and complications.
method. healing in the perineal
reddish in color.
area.
Maintain optimal Health teaching on the Perineal care is most
Objective Data: nutritional and physical proper way of cleaning important to avoid GOAL PARTIALLY
well-being. the perineal area. further complications. MET. Maintained
Nature of delivery: optimal nutritional and
Normal Spontaneous Be informed of various Encourage to choose diet Foods high in protein physical well-being but
Vaginal Delivery with that is high in protein. can contribute to faster still chose to eat more
ways of perineal skin
Midline Episiotomy wound healing.  junk foods.
care routine and
G4P2, 39 weeks by UTZ understand its Teach patient to perform This helps to strengthen GOAL MET. Learned
importance. Kegel exercise.  the muscles in the the various ways on how
V/S vagina and pelvic floor. to give skin care to her
T - 36.5ºC Verbalize feelings of perineum and verbalized
Dependent:
P - 80 bpm strong and increased self-esteem importance of doing so.
regular and ability to manage Administer medications Help prevent
R - 20 cpm without use GOAL MET. Verbalized
situation. as ordered. complications and help
of accessory muscles feelings of increased
BP - 110/80 mmHg ease pain.  self-esteem and ability to
Facial grimace noted. Give hot sitz bath as This is a warm manage current
ordered. therapeutic bath used to situation.
cleanse the perineum
which can promote
faster wound healing.