NURSING CARE PLAN

Patient’s Initials: Carly Chief Complaint: Pain in the Perineal area Name of Student Nurse:
Age & Gender: Female 29 Frenzylane Diane Coral
Birthdate: March 29, 1992 Admitting Diagnosis: Acute Postpartum Perineal Level/Block/Group: 2BSN-11
Pain
Address: Dagupan City Hospital/Area: ________________
Date of Confinement: 09/26/2021 Clinical Instructor:
Mr. Rebenson and Mrs. Apolonia
Date: 09/26/2021

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

ANALYSIS
Subjective:  acute tissue damage  Client will report  The nurse will  Medications from  By the end of the
occurs (perineal pain) that pain administer pain different shift, the client
“It really hurts down there” management medication pharmacological reported that the
as verbalized by the regimen (analgesic, classes targets multimodal pain
patient. achieves her
neurochemical ibuprofen, and different pain regimen was
comfort function local anesthetic) mechanisms. effective in
Objective: reactions at the site
goal by the end as prescribed. Decreases pain reaching her
of injury activates
 Facial mask of pain of this shift. and anxiety. comfort-function
nociceptors
 Guarding behavior goal.
V/S taken as follows:  The nurse will  This will help in
initiate an afferent perform pain differential
 T= 36.7 nerve impulse assessment by diagnosis and in
 PR= 88/min identifying the determining the
 BP= 110/70 type, location, applicable
characteristic, treatment
propagates through
severity, and method.
NURSING DIAGNOSIS the peripheral nerve,
enters the spinal duration of the
 Acute postpartum cord, and synapses pain. Use a pain
perineal pain scale of 0-10
related to vaginal
birth as evidence by
impulse landing in  To assist the  The patient was
verbalizations of
pain and guarding cerebral centers for
behavior interpretation.

Interpretation of the
impulse yields a
response signal

Results from  Patient will be  The nurse will client in exploring able to
activation of able to encourage the methods for the demonstrate the
demonstrate the use of relaxation control of pain. use of diversional
peripheral pain
use of relaxation techniques (e.g., activities and
receptor
skills and deep breathing skills that
diversional exercise) and promotes comfort
activities as diversional and relaxation
Specific A delta and indicated.
activities (e.g.,
C sensory nerve
watching TV).