NURSING CARE PLAN

Client: Rose Ann Fernandez

Care Plan by: Rouwi Desiatco
Date initiated 19 – 10 – 19
NURSING
CUES/EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

Subjective: Altered comfort: acute Within our 3 hours of At the end of nursing
Client verbalized pain related to surgical nursing care the patient care all objectives
that incision secondary to will be able to: were partially met as
 “sumasakit yung episiotomy wound. evidenced by:
tahi ko kapag
gumagalaw ako”  Vital signs in  Monitor patients  To obtain baseline  Vitals signs:
normal range vital signs. data T:36.1 ⁰C
T= 36.5⁰C-37.5⁰C P:91 bpm,
P=60-100bpm regular
Objective: R=15-20cpm R:18 cpm, no use
 VITAL SIGNS BP=110-140/60- of accessory
T: 36.1 ⁰C 90 mmHg muscles.
P: 87 bpm BP:100/60 mmHg
R: 12 cpm
BP: 90/50 mmHg
 Patient report of  Accepts clients  Pain is subjective  The patient was
 Client rate the less pain. percerption of experience and able to observed
pain 4 (1 lowest- pain. cannot be felt by evidence of pain.
10 highest) Acknowledge the others.
pain experience
 Limited movement and convey
 Verbalized feeling acceptance of
of comfort. clients response of
 Facial Grimacing pain.
 Verbalize feeling  Assess patient’s  To determine  The patient
of relief. general health deviations from reports less pain
condition. normal and obtain especially when
subjective cues. she takes her
 On the given, medication and by
administer pain changing her
reliever to the position.
client.
 Provide adequate  Promotes feeling  The patient
rest. of rested, comfort verbalized the
and also avoid feeling of comfort.
fatigue.

 Patient able to  Provide health  To reduce the risk  The patient able
properly clean teaching on the of infection and to understang the
surgery proper cleaning of for proper and cleansing of the
episiorapphy safe healing surgery wound in
process. a right way.

 Each client has a  The client was

 Provide optimal right to expect able to take her
pain relief with maximum pain prescribed
doctor’s relief. Medications medications.
prescribed ordered PRN
analgesics basis should
be offered to  Patient discharged
the client at in good condition
the interval when
the next dose is
available..