NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Acute pain related to After a 7 hour shift of Independent: After a 7 hour shift of
surgical incision nursing interventions, 1. Instruct or assist Sitting position reduces nursing interventions, the
- Patient stated “ang secondary to episiotomy the patient will be able to patient in a sitting physical discomfort patient was able to
sakit ng tahi ko” suture as manifested by report lesser and position report lesser and
pain scale of 8 out of 10, tolerable pain level as tolerable pain level as
- Patient rated 8 out of facial grimace manifested by: 2. Teach patient to Performed three to four manifested by:
10 in terms of pain scale particularly when perform Kegel’s exercise times a day, helps
(10 being the highest, 1 standing up and walking, - Pain scale of at least 5 improve circulation in the - Pain scale of at least 5
being the lowest) discomfort and irritability out of 10 3. Instruct patient to do area thus decreasing out of 10
- No facial grimace breathing exercises physical discomfort - No facial grimace
- No discomfort - No discomfort
- Slight irritability and 4. Advise patient to take Bathing everyday helps - Slight irritability and
most of the time calm warm baths after 24 prevent an infection from most of the time calm
OBJECTIVE: hours occurring
Therefore, the goal was
Vital Signs: 5. Tell the patient that Telling the patient about met
- BP: 120/80 mmHg the pain and discomforts the duration of pain
- T: 36.6 usually lasts more than 3 being experienced will
- RR: 18 bpm days lessen the perception of
- PR: 80 bpm pain and anxiety
Dependent:
- Facial grimace 1. Administer 500 mg Mefenamic acid is used
particularly when tablet of Mefenamic acid to relieve pain
standing up and walking every 6 hours as ordered
by the physician
- Discomfort

- Irritability