NURSING CARE PLAN

ASSESSMENT NURSING PLAN/OBJECTIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective cues: Risk for Pain r/t Short Term:
perineal laceration Dependent: After 7 days of
Patient verbalized aeb facial grimace After 6- 8 hours of nursing intervention,
‘sakit jud ang ako nursing interventions, Instruct the To provide the pain was relieved
kintawo, tungod Client’s pain score patient to take patient comfort and there were no
dagay sa tahi, mao will decrease from the medications if the pain has complaints
hapdos.” Pain scale: 8/10 to 6/10. on time. decreased from verbalized by the
8/10 the pain scale client as evidenced
Long Term: goal. by absence of facial
Objective cues: grimace and a pain
After 7 days of Independent: scale of 0/10.
32-year-old nursing intervention
G4P4 client will have no Positioned In order to heal
farther complaints of patient or fast recovery
perineal pain and is comfortably. after taking
laceration comfortable. medications.
intact

vital signs 10 Linens To have comfort

minutes after stretched for from the pain.
delivery: more comfort.

P – 88 To keep away
BP – 124/70 Keep back dry. from getting a
RR – 20 disease such as
T – 37.1 pneumonia.

O2 Saturation
97% on room V/S taken & be To monitor if
air recorded V/S has
changed from
facial grimace its baseline and
and guarding to assess the
 pt.’s condition.

Collaborative:
Medications
The nurse will from different
collaborate pharmacological
with the classes target
physician to different pain
manage pain mechanisms.
with a Nonopioid
multimodal analgesics are
approach preferred for
consisting of breastfeeding
acetaminophen, mothers.
ibuprofen, and
local
anesthetics.