NURSING CARE PLAN

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Independent
acute pain related to After 4 hours of nursing - Monitor skin - Which are usually After 8 hours of
“Sakit akoang tahi” perineal trauma, intervention, the patient will color and vital altered in acute pain nursing interventions,
experience pain within signs and the patient will
caused by sutured
7/10 pain scale tolerable level temperature experience pain within
laceration, as - To demonstrate tolerable level
verbalized by the After 4 hours of nursing - Perform pain improvement in the patient will report
Objective: patient and intervention, the patient will assessment each status or to identify a pain scale within
 Grimace upon evidenced by the pain report a pain scale within time pain occurs worsening of 3/10 or below, the
movement scale of 7/10. 5/10 or below, the patient underlying condition patient will feel
 Pale will feel comfort and ease, developing comfort and ease,
 Sweating and no presence of grimace complication and no presence of
 Fatigue upon movement. grimace upon
Dependent movement.
 T – 37.8°c
 Pr – 68 bpm - Administer - To maintain
analgesics, as “acceptable” level of
 Rr – 26 cpm
indicated, to pain
 Bp – 90/60
maximum
mmhg
dosage, as
needed.
- Promotes active,
Collaborative rather than passive,
- Provide for role and enhances
individualized sense of control
physical therapy
or exercise
program that can
be continued by
the client after
discharge

NAME: Nathaniel Nogra NAME OF PATIENT: Sorainadiawe Jahi AGE: 19

YEAR LEVEL: BSN 2-I