NURSING CARE PLAN

Name of Patient: Belle Impression/Diagnosis:

Age & Sex: 21, Female Ward/Bed:

DEFINING NURSING OUTCOME NURSING RATIONALE EVALUATION

CHARACTERISTIC DIAGNOSIS IDENTIFICATION/OBJECTIVE INTERVENTION
S

SUBJECTIVE: Pain related to LONG TERM: INDEPENDENT:

mediolateral
Patient complaining episiotomy as After nursing intervention, the Assess psychological Emergency Goals were met
of moderate pain at a evidenced by patient will identify appropriate causes of pain and situations may after nursing
scale of 6/10 pain slightly bruised methods to provide relief from discomfort. precipitate fear, intervention.
scale on episiotomy. and swollen pain. anxiety which Patient was able
perineum and a can raise to verbalize relief
OBJECTIVE: 6/10 pain scale SHORT TERM: perception of from pain and
as claimed by After an hour of nursing pain and discomfort.
T = 37.2°C the patient intervention, the patient will discomfort.
PR = 79 bpm verbalize relief from pain and
RR = 19 bpm RATIONALE: discomfort. Perform pain This will help in
BP = 110/70 mmHg An episiotomy assessment by differential
is an incision identifying the type, diagnosis and in
made in the location, determining the
perineum — the characteristic, applicable
tissue between severity, and treatment
the vaginal duration of the pain. method.
opening and the Use a pain scale of 0-
anus — during 10;
childbirth. The
stitches may Encourage the use of To assist the
make it painful relaxation techniques client in
to sit or walk for (e.g., deep breathing exploring
a little while exercise) methods for the
during healing. control of pain.
It also can be
painful when Provide comfort Ice compress
one coughs or measures such as decreases
sneezes during application of ice edema and
the healing time. pack into the minimizes
perineum, use of sitz hematoma and
NOTE: Nursing bath or heat lamp to pain sensation
Diagnosis episiotomy while heat
should be based extension. promotes
on the (NANDA vasodilation
– Approved which facilitates
Nursing resorption of
Diagnosis) hematoma.

DEPENDENT:

Administer pain Decreases pain

medication as and anxiety;
prescribed. Helps promote
relaxation.

COLLABORATIVE:
Labs:
Hematology,
CBC, Urinalysis
 NURSING CARE PLAN

Name of Patient: Belle Impression/Diagnosis:

Age & Sex: 21, Female Ward/Bed:

DEFINING NURSING OUTCOME NURSING RATIONALE EVALUATION

CHARACTERISTIC DIAGNOSIS IDENTIFICATION/OBJECTIVE INTERVENTION
S

SUBJECTIVE: Impaired LONG TERM: INDEPENDENT:

comfort related
Discomfort claimed to uterine After nursing intervention, the Assess psychological Emergency Goals were met
by the client that contraction as patient will identify appropriate causes of pain and situations may after nursing
strengthens during evidenced by methods to provide relief from discomfort. precipitate fear, intervention.
breastfeeding due to clients complain pain. anxiety which Patient was able
uterine contraction. of moderate pain can raise to verbalize relief
on both breast. SHORT TERM: perception of from pain and
After an hour of nursing pain and discomfort.
OBJECTIVE: RATIONALE: intervention, the patient will discomfort.
Cramping after verbalize relief from pain and
T = 37.2°C the baby is born discomfort and understands the Perform pain This will help in
PR = 79 bpm due to uterine reasons for the discomfort. assessment by differential
RR = 19 bpm contractions identifying the type, diagnosis and in
BP = 110/70 mmHg occur because location, determining the
uterus shrinks characteristic, applicable
back down to its severity, and treatment
original size. duration of the pain. method.
Breastfeeding Use a pain scale of 0-
strengthens 10;
discomfort due
to the oxytocin Encourage the use of To assist the
released that relaxation techniques client in
initiates uterine (e.g., deep breathing exploring
contractions. exercise) methods for the
control of pain.
NOTE: Nursing Educate the client To allay the
Diagnosis regarding the patient’s
should be based discomfort she feels. anxiety.
on the (NANDA
– Approved
Nursing
Diagnosis) DEPENDENT:

Administer pain Decreases pain

medication as and anxiety;
prescribed. Helps promote
relaxation.

COLLABORATIVE:
Labs:
Hematology,
CBC, Urinalysis