Nursing Care Plan
ASSESSMENT NURSING DIAGNOSIS PATHOPHYSIOLOGIC DESIRED OUTCOME INTERVENTION RATIONALE EVALUATION
BASIS
Subjective Data: Altered comfort: Inadequate opening of After 8 hours of 1. Assess the - to provide data
- The patient Acute pain related to the vagina during nursing intervention characteristics of the information on the
experiences pain on surgical incision childbirth the patient will be wound, including extent of damage and
the perineal area secondary to able to: color, size, odor and to compare the
- Client verbalized that episiotomy wound. drainage. gathered data to
“Sakit ang akon nga - experience comfort normal color, size,
tinahian pero medyo Definition: Episiotomy/surgical cut and report of less pain odor and drainage to
pitik-pitik lang man” was made at the in the perineal area detect infection
- The patient rated tha Episiotomy is a opening of the vagina
pain as 5 (1 lowest-10 surgical cut made at during childbirth 2. administer pain - To alleviate the pain
highest) the opening of the medications felt by the patient
vagina during prescribed by your
Objective Data: childbirth, to aid a physician or midwife
- Vital Signs: difficult delivery and Pain on the perineal
T= 36.4 prevent rupture of area caused by the 3. Suggest comfort -To reduce swelling
R= 16 cpm tissues. surgical cut techniques to the and pain. And also
P= 74 bpm patient such as the use provide comfort to the
BP= 120/80 of ice on sore stitches client.
mmhg or sitting and lying
Altered comfort positions
ALFONSO C. JAMORA III
BN 2C November 6, 2019
ALFONSO C. JAMORA III
BN 2C November 6, 2019