Gonzales, Abby B.

BSN 2-7
T1

Nursing Care Plan

Patient: CHRISTINE GOLORAN

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION
SUBJECTIVE DATA: Pain related to Pain is an  After 4 hrs. of 1. Assess 1. To monitor the The goal was met.
episiotomy as unpleasant nursing patient’s pain patient’s pain and After 4 hours of
to prevent it from
 “Masakit yung evidenced by sensory and intervention the throughout increasing and to nursing
tahi ko…mga reports of pain, emotional patient will be the remaining give appropriate intervention the
9” grimaced face, experience that is able to report shift ( with the interventions as patient verbalized
discomfort in associated with reduced pain use of pain needed that the pain
2. To maintain
OBJECTIVE DATA: surgical area and actual or potential from 9 to 5 scale) patient’s comfort
decreased from 9
BP:120/80 with a pain scale tissue damage or (from pain scale 2. Give and for the pain to 5 (from pain
BT: 36.4°C of 9 from a range described in such of 1-10) medications not to increase scale of 1-10) as
PR:85 of 1-10 terms. Pain is  The patient will as ordered by 3. By keeping the evidenced relaxed
RR:20 subjective and be able to the doctor perineum clean facial expression
there will be a less
difficult to display relaxed 3. Teach client chance for
 Medial quantify, because facial how to clean infection that can
episiotomy it has both an expression perineal area cause the patient’s
 Grimaced face affective and a 4. Teach client pain
4. Because sliding it
sensory to lift rather will rub the sore
component. than sliding it perineal area to the
An episiotomy is to the other mattress causing
an incision made bed more irritation
between the 5. Monitor vital 5. To help determine
patient’s current
vagina and the signs and
health status and
rectum in order to record evaluate
increase the size effectiveness of
of the opening of nursing
the vagina and intervention
rendered
facilitate the
delivery of a baby.