EMILIO AGUINALDO

COLLEGE
School of Nursing

NURSING CARE PLAN

NAME: Bryan O. Zabala PATIENT INITIAL: J.L.. AGE: DATE:

STUDENT #: DIAGNOSIS: GENDER: ROOM NO.

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: After 8 hours of nursing INDEPENDENT
Acute pain related to interventions, The patient
“medyo masakit yung post-op surgical will show relief from pain - After 8 hours of
tahi ko sa pwerta” incision - to obtain baseline data nursing
- Monitor the patient's
interventions, the
patient pain was
vital signs
relieved or
Objective: controlled
- Assess the episiotomy - to obtain baseline data
Vital Sign: and facilitate prompt
wound for abnormal treatment
T: 33.9
discharge and signs of
PR: 78

BP: 120/90 infection

O2: 98 - Acknowledge the - Pain is a subjective

experience and cannot
RR: 16 patient’s pain be felt by others
PS: 5/10 -
episiotomy experience and convey

acceptance of patient’s

response
 - To relieve the pressure
- Place the patient in a
on the episiotomy site
comfortable side-lying

position

- To facilitate relaxation
- instruct patient to

perform deep breathing

exercises

DEPENDENT
- To relieve pain
- Administer of
- analgesics as ordered patient
by the physician
-

COLLABORATIVE