Nursing Care Plan #1

ASSESSMENT DIAGNOSIS PLANNING/GOALS IMPLEMENTATION RATIONALE EVALUATION

Date: October 30, 2019 Independent:
Subjective: Acute pain After 2 hours of  evaluate client’s response  To know the severity of After 2 hours of
“Kapag gumagalaw ako related to tissue proper nursing care to pain the pain proper nursing
mahapdi yung sa may tahi” trauma along with patient  Assist the client to explore  For the client to be able care along with
as verbalized by the secondary to education, the patient methods for to properly manage the patient education,
patient Episiotomy as will be able to report alleviation/control of pain pain the patient’s pain
manifested by that the pain was  Instruct the client to apply  To reduce pain was alleviated
Objective: painscale of reduced from a pain a cold compress from the pain
Guarding Behavior 8/10 scale of 8/10 to 4/10,  Promote perineal  To reduce discomfort scale of 8/10 to
Facial Grimace and verbalize exercise and 4/10, and was able
Immobility
appropriate methods comfortable sitting to demonstrate
Pain Scale: 8/10
to provide relief. position such as Kegel’s appropriate
exercise and sitting methods to
Vital signs as follows: provide relief.
–T: 37.3℃ position
–PR: 93  Demonstrate
appropriate perineal  To prevent infection
–RR: 16
hygiene and the proper
–BP:110/70
ways of cleaning the
suture
 Monitor client’s vital  To observe for infection
signs

Dependent:
 Administer analgesic as  To relieve pain
ordered by physician
 Nursing Care Plan #2

ASSESSMENT DIAGNOSIS PLANNING/GOALS IMPLEMENTATION RATIONALE EVALUATION

Date: October 31, 2019 Independent:
Subjective: Fatigue related After 4 hours of  Ask for the client’s  To assess for After 4 hours of
“Nanghihina din po ako to sleep proper nursing care activities of daily living contributing factors proper nursing
kasi di po ako makatulog deprivation along with patient care along with
ng maayos” as verbalized secondary to education, the patient  Use electric fans, and  To provide proper patient education,
by the patient pain as will be able to take an open windows and door ventilation the patient was
manifested by adequate sleep, and be able to take an
Objective: listlessness able to understand the  Position the patient in a  To provide comfort adequate sleep,
Listless ways to develop an semi-fowlers position and was able to
Drowsy appropriate sleeping demonstrate ways
pattern.  Instruct the client to wear  To provide comfort to develop an
Tired
light clothing appropriate
Vital signs as follows:
sleeping pattern.
–T: 36.3℃
 Instruct the client to have  Vasodilation provides an
–PR: 88
a warm bath before increase of blood supply
–RR: 16
sleeping in the brain that helps
–BP:120/80
induce sleep

 Advice the client to avoid  Daytime naps affects the

daytime naps ability to sleep at night

 Advice the client to limit  Night time elimination

fluid intake before may interfere with the
sleeping client’s sleep

Dependent:
 Administer analgesic as  To relieve the pain
ordered by physician