NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain related Short term: After an Independent: Independent:

“Sakit akon tahi kag to post operative hour, the patient’s pain 1.Establish rapport. 1. To establish a good nurse-
kung kis-a man, may procedure or will be reduced 0/10 2. Assess quality- tingling patient relationship
times nadi kayo ko ka episiotomy as from 4/10 by verbalizing. sensation, and severity of pain 2. To establish baseline data
ginhawa kay siguro evidence by 4/10 3. Provide the patient for comparison in making
sakon na tahi kung pain rating scale Long term: After 7 hours comfortable environment- evaluation.
mag hulag ko” as and in pain while of nursing intervention, change linen and provide air by 3. A clean environment
verbalized by the slightly moving. the patient will show turning on the fan, if ensures comfort and helps to
patient. relief from pain with unavailable, help them provide decrease the anxiety of the
positive coping air refreshments using hand patient and is likely to help
Definition: mechanisms - The fans. decrease the pain.
Due to episiotomy patient will not have 4. Encourage and help the 4. For patient to find a
Objective: or post complaints of pain. patient in position changes comfortable position.
-Pale operative 5. monitor vital signs every q4. 5. to assess potential concerns
-Diaphoretic procedure, there is and well being
-in pain while walking an increased risk for Dependent: Administer
-physically weak being invaded by analgesics as ordered by the Dependent: To relieve pain of
-restlessness pathogenic physician patient
-facial grimace organisms,
Pain scale: 4/10 lacerations, and
RR: 1ST take-26 cpm. broken skin destroy
2nd take-25 cpm. the body’s first line
of defense, the skin.

Bsn2b
 NURSING CARE PLAN
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain related Short term: After an Independent: Independent:

“Sakit lang gid akon to post operative hour, the patient’s pain 1.Establish rapport. 1. To establish a good nurse-
tahi” and “burning procedure or will be reduced 0/10 2. Assess quality- burning patient relationship
sensation” as episiotomy as from 4/10 by verbalizing. sensation, from 4/10 2. To establish baseline data
verbalized by the evidence by 4/10 3. Provide the patient for comparison in making
patient. pain rating scale Long term: After 7 hours comfortable environment- evaluation.
and in pain while of nursing intervention, change linen and provide air by 3. A clean environment
slightly moving. the patient will show turning on the fan, if ensures comfort and helps to
relief from pain with unavailable, help them provide decrease the anxiety of the
positive coping air refreshments using hand patient and is likely to help
Objective: Definition: mechanisms - The fans. decrease the pain.
-Pale Due to episiotomy patient will not have 4. Encourage and help the 4. For patient to find a
-Diaphoretic or post complaints of pain. patient in position changes comfortable position.
-in pain while moving operative 5. monitor vital signs. 5. to assess potential concerns
-guarding behavior procedure, there is and well being
- facial grimace an increased risk for Dependent: Administer
-restlessness being invaded by analgesics as ordered by the Dependent: To relieve pain of
Pain scale: 4/10 pathogenic physician patient
PR: 112 bpm organisms,
lacerations, and
broken skin destroy
the body’s first line
of defense, the skin.

Bsn2b