NURSING CARE PLAN

Patient's name: I.M.S. Hospital No.: 0910076532

Age: 23 Room No.: Aboitiz Ward 11
Impression/Diagnosis: Acute Pain due to episiotomy Physician: Dr. Raida G. Varona
Nurse's Name & Signature: CASTILLO, RENETTE THELMA B., S.N.
CLINICAL PORTRAIT PERTINENT DATA

1. Assessment 1. Present Illness

A case of I.M.S., female, 23 years old, Roman Catholic, having a A case of I.M.S., female, 23 years old, Roman Catholic, having
live-in partner, came in for delivery. Upon assessment, patient was conscious, a live-in partner, came in for delivery, (-) smoker, (-) alcoholic drinker,
coherent, oriented, reported pain scale of 8(range 1-10), with grimaced face, (-) HPN.
weak, eye bags noted on both eyes, limited movements with an IVF of D5LR
at 40 gtts./ min infusing well, non-smoker, non-alcoholic drinker, non-HPN. 2. Chief Complaints

2. Significant Findings Patient came in for delivery.

Patient verbalized that she was in pain due to episiotomy. Patient

also expressed that she was sleepless for two straight days because of 3. Health History
labor. She expressed complete happiness for her normal delivery.
No previous hospitalizations.
3. Vital Signs

BP= 110/70 mmHg P= 78 bpm 4. Vital signs

T= 36.7 C RR= 20 cpm
BP= 110/ 70 mmHg P= 84 bpm
4. Priority Nursing Problem T= 35.8 C RR= 20 cpm
1. Acute Pain
 CUES NURSING SCIENTIFIC GOALS & NURSING ACTIONS RATIONALE EVALUATION
DIAGNOSIS BASIS OUTCOME & NURSING OF NURSING
CRITERIA INTERVENTIONS ORDERS
S-" Sakit jud Pain r/t surgical Pain is a highly After 8 hours of 1.A. Assess pain 1.A. Assessment of Goal met.
gihapon ang akong incision (episiotomy) subjective state in nursing intervention, characteristics. pain experience is
tinahi-an." as as evidenced by which a variety of the patient will be the first step in After 8 hours of
verbalized by the reports of pain, unpleasant sensation able to report pain B. Observe or planning pain nursing intervention,
patien. grimaced face, dis- and a wide range of reduced/ controlled. monitor signs and management the patient was able
comfort in surgical distressing factors symptoms associat- strategies. (Gulanick/ to report a dec-
O-Patient seen lying area, with a pain may be experienced Specifically, the ed with pain Myers: Nursing Care reased pain sensa-
on bed, conscious, scale of 8( range by the sufferer. Pain patient will be able to: Plans: Nursing tion from pain scale
coherent, weak, eye- 1-10) may be a symptom C. Assess patient's Diagnosis and 8(range 1-10) to 3
bags noted on both of unjry or illness. 1. Verbalizes knowledge of or Intervention, 6th and displayed a
eyes, with grimaced Pain may also arise adequate relief of preference for the edition:145) relaxed facial
face, with limited from emotional, pain or ability to cope array of pain relief expression.
movements, with a psychological, with incompletely strategies available. B. Some people
pain scale of 8(range cultural, or spiritual relieved pain. deny the experience
1-10) w/ ongoing IVF distress. Pain can be 2.A. Evaluate the of pain when it is
of D5LR at 40 gtts./ very difficult to 2. Demonstrates use patient's response present. Attention to
min., infusing well. explain, because it of relaxation skills and medications or associated signs
is unique to the or divertional therapeutics aimed may help the nurse
individual. One of activities as indicated at abolishing or in evaluating pain.
the forms of pain for his condition. relieving pain. (Gulanick/Myers:
is characterized by Nursing Care Plans:
episiotomy. 3. Display relaxed B. Assess the Nursing Diagnosis
Episiotomy is a surgi- facial expression. patient's willingness and Intervention, 6th
cal cut in the muscular or ability to explore edition:145)
area between the a range of techniques
vagina and the anus aimed at controlling C.Some patients may
(perineum)made just pain. be unaware of the
 PATIENT'S OUTCOME CRITERIA
5. Diet
5.1 Explain dietary regimen
to be followed.
EVALUATION
1.Evaluate self-compliance
of all treatment regimens.
2. Evaluate progress of the
patient's health condition.
NURSING ORDER
Encourage patient to eat nutri-
tious foods such as foods rich in protein
which facilitates tissue repair, high-fiber
foods for hemorrhoids, milk for lactation,
plenty of fresh fruits and vegetables, and
the like.
Encourage patient to follow
dietary regimen as given by the doctor or
dietician.
Discuss to the patient and the
SO the importance of evaluating self-
compliance in order to monitor the
patient's condition.
Encourage the patient and the
SO to monitor,take note and evaluate any
progress on the patient's health in order
to know whether the patient is improving
or not.
tient to eat nutri-
ds rich in protein
repair, high-fiber
milk for lactation,
d vegetables, and

tient to follow
n by the doctor or

patient and the

valuating self-

e patient and the

e and evaluate any
's health in order
tient is improving
BIBLIOGRAPHY:

Doenges, Marilyn, et al. Nursing Care Plans. 6th edition. Thailand: F.A. Davis Company, 2002.

Gulanick, Meg, et al. Nursing Care Palns: Nursing Diagnosis & Interventions. 6th edition.
Philippines; Elsevier, 2007

www.wikipedia.org

www.dictionary.com

www.babycenter.com

www.health.com
 PATIENT'S OUTCOME CRITERIA
2. Exercise
2.1 Perform postpartum
care
3. Treatment
3.1 Comply with the medica-
tion regimen, follow-up check-ups,
and dietary instructions and proper
care.
4. Health Teaching/Hygiene
4.1 Demonstrate the proper
way postpartum care.
NURSING ORDER
Encourage the patient to
exercise and the SO to facilitate. Exercise
promotes faster wound healing.
Simple exercises could be as
follows:
1. Begin doing Kegel's exercise
(exercise that will help the pelvic floor
muscles contract to support the wound.)
2. The client can abduct her legs
slowly.
Explain to the patient and the SO
the importance of compliance of
check-ups and compliance of therapies
Discuss to the patient and the SO
the correct way of post partum care.
Post partum care are as follows:
1. Soak in a warm tub or sitz bath.
2. Keep the area dry and exposed
to air as much as possible.
3. Perform Kegel exercise that
will stimulate circulation and promote
healing.
4. Apply ice packs to reduce
swelling.
5. Use special perineal pad that
are soothing or sanitary pads.
6. Avoid constipation and don't
strain to move your bowels.
7. Sit carefully, and on one cheek
possible.
exercise and the SO to facilitate. Exercise

Simple exercises could be as

1. Begin doing Kegel's exercise

(exercise that will help the pelvic floor
muscles contract to support the wound.)
2. The client can abduct her legs

Explain to the patient and the SO

check-ups and compliance of therapies

Discuss to the patient and the SO

Post partum care are as follows:

1. Soak in a warm tub or sitz bath.

2. Keep the area dry and exposed

3. Perform Kegel exercise that

will stimulate circulation and promote

4. Apply ice packs to reduce

5. Use special perineal pad that

6. Avoid constipation and don't

7. Sit carefully, and on one cheek

 PATIENT'S OUTCOME CRITERIA
3. Discuss on how to assess
and prevent edema.
4. Discuss on how to asses
phantom sensation on the wound area.
PLANNING:
1. Plan ahead the return visit
the return to the doctor's clinic or
hospital for further checkup.
2. Make a chart or note the
progress of wound healing.
IMPLEMENTATION:
1. Medication
1.1 Comply with the medication
NURSING ORDER
Discuss to the patient and the
SO on how to assess and prevent
edema.
Edema- is an abnormal
accumulation of fluid beneath the skin, or
in one or more cavities of the body.
Ways on how to control edema:
1.Keep off your feet.
2. Reduce your salt intake.
3. Drink more water.
4. Avoid heat as much as possible.
Encourage the patient and the
SO to report immediately to the health
care provider if there is presence of
edema.
To avoid misunderstandings,
inform the patient and the SO that phan-
tom sensation on wound area normally
occur.
Remind the patient and the SO
to schedule a return visit for monitoring
until the client has adjusted to her new
situaton and feel reasonably comfortable
in her ability to provide self-care.
Encourage the patient and the SO
to note the progress of wound healing
and also note the abnormal manifestations
for further monitoring.
Discuss to the patient and the SO
the importance of completing one's
medication, using language that the patient
can understand.
Encourage the patient to vice
their concerns and questions about the
medications. Be aware of nonverbal
behaviors.
Encourage the patient to follow
the medication regimen religiously.
 patient and the

eneath the skin, or

to control edema:

as much as possible.

e patient and the

ly to the health

nderstandings,
he SO that phan-
d area normally

atient and the SO

it for monitoring
sted to her new
nably comfortable

e patient and the SO

wound healing
rmal manifestations

patient and the SO

uage that the patient

e patient to vice
stions about the

e patient to follow
 DISCHARGE PLAN

Patient's Name: I.M.S. Hospital No.:09100076532

Age: 23 years old Room No.: Aboitiz Ward 11
Impression/Diagnosis: Acute Pain Physician: Dr. Raida G. Varona
due to episiotomy
Nurse's Name and Signature:CASTILLO, RENETTE THELMA B.,SN.

PATIENT'S OUTCOME CRITERIA NURSING ORDER

As soon as the patient is

discharged from the hospital, the
patient and the S.O. will be able to
acquire basic knowledge and skills
and positive attitude on postpartum.

Specifically, the patient

will be able to:

ASSESSMENT:

1. Discuss some methods on Discuss to the patient and the

postpartum care such as: SO some methods on post partum care
such as:
a. hot sitz bath a. hot sitz bath - is a form of
b. perilight hydrotherapy. Taking one in hot water
helps relieve conditions, reduce swelling
and discomfort and also promte healing.
This can be taken for as long as 10-15 min.

b. perilight- is a device for easy

healing of the perineum. The heat of the
light promotes faster circulation in the
blood vessels around the perineum.
Good circulation in the site is giving it
ample of tissue repair and nutrients need
for healing.

2. Discuss the different signs Infection - it occurs when the

of infection and ways to prevent it. microorganisms colonizing the wound
multiply excessively or invade tissues.

Different Signs and Symptoms of

Infection:

1. pain, redness, swelling

2. itching, burning, or a foul
smelling discharge from your vagina
3. fever

Ways of preventing infection:

1. Do proper hygiene.
2. Keep site clean and do warm
moist compresses.
 patient and the
ost partum care

h - is a form of
ne in hot water
s, reduce swelling
o promte healing.
s long as 10-15 min.

a device for easy

m. The heat of the
rculation in the

site is giving it
nd nutrients need

ccurs when the

zing the wound
invade tissues.

s and Symptoms of

ning, or a foul
m your vagina

nting infection:

ean and do warm

CUES NURSING SCIENTIFIC GOALS & NURSING ACTIONS RATIONALE EVALUATION
DIAGNOSIS BASIS OUTCOME & NURSING OF NURSING
CRITERIA INTERVENTIONS ORDERS
tension and irritability.
(Doenges, Moorhouse,
& Murr, 2006:p.601)
CUES NURSING SCIENTIFIC GOALS & NURSING ACTIONS RATIONALE EVALUATION
DIAGNOSIS BASIS OUTCOME & NURSING OF NURSING
CRITERIA INTERVENTIONS ORDERS
ed.:p.144, www. Nursing Care Plans:
babycenter.com) Nursing Diagnosis and
Intervention, 6th ed.:
p.145)

3.A. A quiet environ-

ment and all measures
geared toward
facilitating rest.
(Gulanick/Myers:
Nursing Care Plans:
Nursing Diagnosis
and Intervention, 6th
edition:145)

B. Usually provide
adequate control of
pain and inflamma-
tion and reduces
muscle tension,
which improves
clients' comfort and
promotes healing.
(Doenges,Moor-
house & Murr,2006:
102)

C. Draining bladder
reduces bladder
CUES NURSING SCIENTIFIC GOALS & NURSING ACTIONS RATIONALE EVALUATION
DIAGNOSIS BASIS OUTCOME & NURSING OF NURSING
CRITERIA INTERVENTIONS ORDERS
results to hematoma. (Gulanick/Myers:
These serious tears Nursing Care Plans:
result in more perineal Nursing Diagnosis
pain after the birth, and Intervention, 6th
require significant edition:145)
longer recovery period
and are more likely to B. Some patients will
affect the pelvic floor feel uncomfortable
muscles. Tears that exploring alternative
disrupt the anal methods of pain relief.
sphincter make it However, patients need
more likely that that to be informed that
the mother will have there are multipe ways
anal incontinence. to amnage pain.
But, studies show that (Gulanick/Myers:
episiotomy offers your Nursing Care Plans:
vaginal tissue and Nursing Diagnosis
pelvic floor muscles and Intervention, 6th ed.:
no evidence of protec- p.145)
tion, and the proce-
dure may actually C. Techniques are
cause problems. used to bring about a
For this reason, this state of physical and
should not be done mental awareness and
routinely. tranquility. The goal
(Gulanick/Myers: of these techniques is
Nursing Care Plans: to reduce tension,
Nursing Diagnosis subsequently reducing
and Intervention, 6th pain. (Gulanick/Myers:
CUES NURSING SCIENTIFIC GOALS & NURSING ACTIONS RATIONALE EVALUATION
DIAGNOSIS BASIS OUTCOME & NURSING OF NURSING
CRITERIA INTERVENTIONS ORDERS
before delivery to en- C. Demonstrate effectiveness of non-
large vaginal opening. relaxation exercises, pharmacological
Womwn who have an biofeedback methods and may be
episiotomy tend to breathing exercises, willing to try them, either
lose more blood at the music therapy. with or instead of
time of delivery, have traditional analgesic
more pain during reco 3.A. Provide rest medications. Often a
very, and have to wait periods to facilitate combination of
longer before they comfort, sleep, and therapies may be most
have sex without relaxation. effective. (Gulanick/
discomfort. Episio- Myers: Nursign Care
tomy increases the B. Administer Plans: Nursing
risk of infection,and medications as Diagnosis and Inter-
a recent study showed indicated, eg.propo- vention, 6th ed.: p145)
that getting an episio- xyphene and acita-
tomy for a first vaginal minophen & oxyco- 2.A. It is important
birth is linked to an done(Tylox) to help patients
increase risk of tear- and/or ketorolac express as factually
ing in the next birth. (Toradol) as possible the effect
Episiotomies are in of pain relief measures.
an area abundant with C. Insert catheter Discrepancies between
bacteria. So, it is and attach to behavior or appearance
important to keep straight drainage as and what the patient
area clean as possi- indicated. says about pain relief
ble. Pain felt during may be more a reflect-
this procedure can ion of other methods
be excruciating and that the patient is using
severe rectal pressure to cope with than
may occur which pain relief itself.