NURSING CARE PLAN 2

Nursing Care Plan

Nursing
Assessment Expected outcomes Interventions Rationale Evaluation
Diagnosis
Objective: Acute Pain r/t 1. Client will report no 1. a) Assess pain level in a client 1. a) Single- -Pt will report no
-Pt vaginally childbearing, pain, or that pain using a valid and reliable self- dimension pain pain or pain at a
delivered a live including perineal management regimen report pain tool, such as the 0-10 ratings are valid and functional level
female tear AEB clients reduces pain to a numerical pain rating scale (0=no reliable as measures during stay in
-Pt has a verbalizations of functional level before pain, 10= most pain possible). of pain intensity level hospital
perineal tear pain she is discharged. (Ackley & Ladwig,
2011, p. 601).
Subjective:
-Pt states they 1. b) Assess the client for pain 1. b) Pain assessment
are presence routinely at frequent is as important as
experiencing intervals, at the same time as vitals physiological vital
pain are taken. signs and pain is
considered the “fifth
vital sign” (Ackley &
Ladwig, 2011, p.
602).
1. c) Administer an opioid 1. c) Opioids are
analgesic if indicated for moderate indicated for the
to severe pain as per doctors treatment of moderate
NURSING CARE PLAN 3

orders to severe pain

(Ackley & Ladwig,
2011, p. 603)

2. Client will express 2. a) Manage acute pain using a 2. a) The advantage -Client will
understanding of pain multimodal approach of a multimodal articulate
and pain management, approach is that the understanding of
including non- lowest effective dose pain management
pharmacological of each drug can be before leaving the
methods of analgesia, administered, hospital
and adverse effects of resulting in fewer or
analgesics. less severe adverse
effects (Ackley &
Ladwig, 2011, p.
603).

2. b) Avoid giving pain 2. b) IM injections

medication intramuscularly (IM)
when possible.
are painful, result on
unreliable absorption,
and lead to variable
blood levels of the
administered
NURSING CARE PLAN 4

medication (Ackley
& Ladwig, 2011, p.
603).

2. c) Administer opioids orally or 2. c) IM injections

intravenously (IV).
are painful, result on
unreliable absorption,
and lead to variable
blood levels of the
administered
medication (Ackley
& Ladwig, 2011, p.
603).

Objective: Deficient 1. Client will state 1. a) Assess the client/family 1. a) Caregivers -Client will feel
-G1P0 Knowledge r/t confidence in her learning needs, information needs, express a need for confident in her
Subjective: primipara status ability to manage and current level of knowledge. having their ability to leave
-Pt states that AEB client situation and remain in informational needs the hospital and
she “is nervous history control of life before met (Ackley & care for the new
that this is all she is discharged. Ladwig, 2011, p. baby
really 520).
happening now”
NURSING CARE PLAN 5

1. b) Consider the client’s ability 1. b) Each client is

and readiness to learn (e.g., mental unique, and client
acuity, ability to see and hear, motivation, beliefs,
existing pain, emotional readiness, and expectations will
motivation, and previous influence learning
knowledge) when teaching clients. (Ackley & Ladwig,
2011, p. 518).

1. c) Engage clients as a partner in 1. c) A nursing

the educational process. approach that is
collaborative and that
uses encouragement
and support to
increase self-efficacy
resulted in client
satisfaction,
empowerment, and
confidence (Ackley
& Ladwig, 2011, p.
518).

2.Client will list 2. a) Engage clients as a partner in 2. a) A nursing -Client will

NURSING CARE PLAN 6

resources that can be the educational process. approach that is articulate/show

used for more collaborative and that resources she can
information and uses encouragement use to support her
support after discharge, and support to through life
before she is increase self-efficacy changes before
discharged. resulted in client she is discharged.
satisfaction,
empowerment, and
confidence (Ackley
& Ladwig, 2011, p.
518).

2. b) Use individualized 2. b) Individualized

approaches that support client educational
priorities, preferences, and choice. interventions have a
positive effect on
client outcomes
(Ackley & Ladwig,
2011, p. 518).
3. c) Consider coordinated, 2. c) Coordinated
multifaceted methods of efforts using a
disbursing information. combination of
NURSING CARE PLAN 7

written and verbal

information have
proven beneficial for
self-care behavioral
change (Ackley &
Ladwig, 2011, p.
518).

Risk for Bleeding 1.Pt will maintain 1. a) Check vital signs at frequent 1. a) Watch for -Pt’s vital signs
r/t childbearing stable vital signs with intervals, according to AHS policy changes associated will remain stable
AEB risk minimal blood loss on 3A. with bleeding -Pt will have
statistics both before and after including increased minimal blood
her discharge. heart rate, respiratory loss
rate, and eventually
decreased blood
pressure. (Ackley &
Ladwig, 2011, p.
170).

1. b) Assess for clinical signs and 1. b). Blood loss is

symptoms of blood loss, such as frequently
dizziness, fatigue, tachycardia, and underestimated
NURSING CARE PLAN 8

hypotension. (500mL for vaginal

delivery). (Ackley &
Ladwig, 2011, p.
171).

1. c)Assess fundus and lochia 1. c)Vigorous

amount regularly, according to massage and
AHS policy on 3A. downward pressure
should be avoided
(Ackley & Ladwig,
2011, p. 171).

Ackley, B. J. & Ladwig, J. B. (2011). Nursing diagnosis handbook. An evidence based guide to planning care (9th ed.). St. Louis,
MO: Mosby.