DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: _____Narda_____Date of Admission: ___October 01 2022___Room: _Postpartum Unit_ Age: __29_ Sex: __F_Civil Status: ___Married____ Chief
Complaint: _Pain on the incision site_Religion: _____Attending Physician:__________________________________
DATE/TIM PROBLEM SCIENTIFIC BASIS GOALS/OBJECTIVES NURSING RATIONALE EVALUATION
E CRITERIA INTERVENTIONS

October Subjective: “ Acute pain related to Within the 8-hour span Independent: “Goal Met”
01 , 2022 “ Ma’am nagsakit lage Tissue Damage as of care the patient will
1. ) Perform pain Rationale: This will help After 8 hours span o
ang diri sako tinahian” evidenced by pain at be able to:
assessment by in differential diagnosis care, the patient wa
- As verbatim by the the perienal area”
 Identify identifying the pain’s and in determining the able to :
patient.
Rationale: appropriate type, location, applicable treatment
Perineal hematomas or methods to provide characteristic, severity, method. The Numerical  Identifies
Objective:
extensive perineal relief from pain. and duration. Use a pain Rating Scale provides appropriate
-Perineal tear/
lacerations may cause  Demonstrate the scale of 0-10. enough response method to provide
laceration due to
discomfort or pain for use of relaxation options to allow for relief from pain
mediolateral
the client. If the client skills and adequate precision in
Episiotomy
reports severe pain in diversional rating intensity, while at  Demonstrated the
- weak to get out of
the perineal area or a activities as the same time, the 0 to use of relaxation
bed
feeling of pressure indicated. 10 scale provides the skills and
-Pale client with some limits in
between her legs, a  Verbalize relief diversional
-Tired the number of
hematoma could be from pain and activities as
-Sleepy responses; limits which
causing this. In the case discomfort. indicated.
of the patient she may help minimize the
Vital Signs:
eundergo a mediolateral complexity of the rating  Verbalized relief
Blood Pressure: 80/50 task (Pathak et al.,
episiotomy which causes from pain and
(hypotensive)
redness and drainage on 2018). discomfort
Pulse Rate: 105 bpm
her perineal area, she
(hypothermia) Rationale: If the client
complained pain on the
Cardiac Rate: 105 bpm incision site. 2. ) Inspect the client’s reports severe pain in
(tachycardic) The overlying skin is perineal area for the the perineal area or a
intact with no noticeable presence of a feeling of pressure
trauma. However, blood hematoma. between her legs,
accumulates underneath inspect the perineal area
from injury to blood to see if a hematoma is a
vessels in the perineum cause. If a hematoma is
during birth. They may present, it appears as an
occur at the site of an area of purplish
episiotomy or laceration discoloration with
repair if a vein was obvious swelling. At first,
punctured during it may feel fluctuant, but
suturing. as seepage into the area
continues, and tissue is
drawn taut, it palpates
as a firm globe and feels
tender.
Rationale: One of the
typical signs of
3. ) Assess the client’s subinvolution is pelvic
fundal height regularly pain or heaviness.
Subinvolution is a slower
than expected return of
the uterus to its
nonpregnant condition.
The client should report
persistent pain in the
pelvic area because it
may also indicate the
presence of mild
endometritis.
Rationale: Relaxation
4. ) techniques help the
Encourage relaxation client explore methods
techniques (e.g., deep for the control of pain.
breathing exercise) and Guided imagery, deep
diversional activities breathing exercises,
(e.g., watching TV). back rubs, or diversional
activities such as
watching TV or listening
to music may distract
the client from the
presence of pain.
Rationale: The cold
application can limit
5. ) Provide comfort small hematomas on the
measures such as vulva because these
applying an ice pack into applications reduce
the perineum. blood flow to the area;
cold also numbs the
area and makes the
client more comfortable.
Rationale: Frequent sitz
6. ) Promote using a hot baths or soaking the
sitz bath or a heat lamp wound area in a small
to episiotomy extension. number of warm water
for about 20 minutes
several times a day can
help the area clean and
improve the wound
healing. Studies indicate
that a hot sitz bath with
plain water reduces
episiotomy pain and
enhances wound healing
in postnatal mothers. It
 is also a cost-effective
and convenient
intervention when the
client has been
discharged to
recuperate at home
(Viswanath, 2018).
Rationale: Pain at the
7. )  Encourage the episiotomy site usually
client to eat high-fiber occurs, especially due to
foods and increase fluid postpartum
intake to constipation. High-fiber
avoid constipation and foods, such as fruits and
prevent straining. vegetables, can help
relieve symptoms and
prevent constipation
during the postpartum
period. Fiber is
indigestible, adds bulk to
the stool, and stimulates
bowel movements; it
also improves digestion,
helps the woman
reestablish bowel habits,
and prevents
constipation by
softening the stools
without straining and
putting stress on the
suture lines. Adequate
fluid intake will help
soften the stool and
ease bowel movement,
 thus preventing
constipation (Turawa et
al., 2020).
Dependent:

Rationale: Administer
mild analgesics as
8. ) Administer pain prescribed for relief of
medications (analgesic, pain. Suppose the
narcotic, or sedative) as laceration is extensive or
prescribed. difficult to repair. In that
case, it may be
necessary for the client
to be given a regional
anesthetic to relax the
uterine muscle and
prevent pain. Explain the
need for an anesthetic
and the procedures
being carried out.
Rationale: Osmotic
laxatives help retain
9. ) Administer laxatives water in the colon,
for postpartum thereby softening the
constipation as stool and increasing the
prescribed. volume of stools. A stool
softener softens the
stool and enhances easy
defecation. Stimulant
laxatives directly
stimulate the afferent
nerves and irritate the
 intestinal wall, thereby
easing bowel movement
(Turawa et al., 2020)
Rationale: Perineal
10.) Assist in the repair lacerations are sutured
of perineal lacerations. and treated the same as
an episiotomy repair.
Ensure the degree of the
laceration is
documented because
clients with fourth-
degree lacerations need
extra precautions to
avoid having sutures
loosened or infected.
Any client with a third-
or fourth-degree
laceration should not
have an enema or a
rectal suppository
prescribed or have her
temperature taken
rectally because the
hard tips of equipment
could open sutures to or
include those of the
rectal sphincter.

REFERENCES: 8
Postpartum Hemorrhage
Nursing Care Plans -
SNurseslabs
BBN/DTS/2020
________________________________
 ____ NAME OF STUDENT

Nursing Program
NURSING CARE PLAN

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: __NARDA____________________________________ Date of Admission: ___________________ Room: _Recovery Room_________ Age:
__29_______ Sex: __F_____ Civil Status: _Married______ Chief Complaint: ___Pain on the incision site__________________________________ Religion:
____________________ Attending Physician: __________________________________