DE BELEN, Hanna Mae A.

N2A
NURSING CARE PLAN
(EPISIOTOMY WOUND)
CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Altered comfort: Acute Within our 2 days of At the end of our care all
Client verbalized that pain related to surgical nursing care the patient objectives were partially
 “Kumikirot ang tahi incision secondary to will be able to: met as evidenced by:
ko” episiotomy wound.
 Vital signs in  Monitor patients’  To obtain baseline T= 37.1C warm to
normal range vital signs. data touch
Objectives: T= 36.5C-37.5C P=73bpm, regular
 VITAL SIGNS P= 60-100bpm R= 21 cpm, no use
T: 36.6 R= 15-20cpm of accessory
R: 20 BP= 110-140/60- muscles.
P: 72 90mmHg
BP: 120/70
 Observed  Accept client  Pain is subjective  The patient was
 Client rate the pain evidenced of pain perception of pain. experience and able to observed
Of 4 (1 is lowest Acknowledged the cannot be felt by evidence pain.
and 10 as highest) pain experience and others.
convey acceptance
 LABORATORY of client’s response
RESULT of pain.
URINALYSIS
Color: yellow
Transparency:
Slightly hazy  Patient report of  Assess patient’s  To determine  The patient report
Sp. Gravity: 1.030 less pain general health deviations from less pain especially
Glucose: negative condition. normal and obtain when she takes her
subjective cues. medication.
 Profused sweating
 Restless  Verbalized feeling  Provide adequate  Promotes feeling of
 Facial Grimacing of comfort rest. rested, comfort and  The patient
also avoid fatigue. verbalized the
 Verbalize feeling of  Perform cleansing  To cleanse the body feeling of comfort.
relief. bed bath to the and feeling of relief  The patient able to
patient. also to reduce the verbalize feeling of
risk of infection. relief from
 On the given,  Provide optimal  Each client has a cleansing bed bath.
administer pain pain relief with right to expect  The client was able
reliever to the client doctor’s prescribed maximum pain to take her
analgesics. relief. Medications prescribed
ordered PRN basis medications.
should be offered to
the client at the
interval when the
next dose is
available.