Caraca, Nathalie Kate D.

Nursing Care Plan- OB Ward

Group J-2 (BSN 2-4) Prof. Francis Mercado

VII. Nursing Care Plan

Assessment Nursing Diagnosis Scientific Inference Planning Nursing Intervention Rationale Evaluation

Subjective: Actual impairment Vaginal opening is Long-Term: 1. Assess and 1. To detect for Goals are met as
of skin integrity in not large enough inspect the any signs and evidenced by the
“Mahirap the perineum to accommodate After nursing status of the symptoms of improved skin
gumalaw kasi related to the expulsion of intervention, the perineum possible integrity and
masakit, mahapdi episiotomy wound the fetus client will have an infection episiotomy fully
pa rin yung sa tahi secondary to improved skin 2. Assess and healed without
ko” normal birth An incision is made integrity as evident monitor for 2. To prepare or any infection
delivery. in the perineum by episiotomy any signs and perform the
Patient states pain (Episiotomy) to being fully healed symptoms of immediate
is 7/10 when help enlarge the in due time infection such intervention
asked to rate the vaginal opening for without any as fever and a required
pain the delivery of the infection foul-smelling
fetus vaginal 3. Analgesics
Objective: Short-Term: discharge help in
reducing pain
Episiotomy wound Bleeding After nursing 3. Administer felt by the
is still fresh, red intervention, the analgesics as client due to
and swollen client will ordered by the
Altered epidermis/ the doctor episiotomy
Vaginal discharge skin integrity due Be able to identify
(lochia) is still red to episiotomy signs and 4. Teach and 4. As this will
and moderate in wound symptoms of instruct the help maintain
amount infection that can patient about skin integrity
further impair skin the proper as well as
Client grimaces integrity removal of the prevent
Caraca, Nathalie Kate D. Nursing Care Plan- OB Ward
Group J-2 (BSN 2-4) Prof. Francis Mercado

during movements perineum pad, infection to

with her hands on Be able to emphasizing the perenium
abdomen independently the “number
perform caring 7” technique 5. To maintain
procedures for the its cleanliness
episiotomy wound 5. Teach the prevent
client about infection
Understand and proper
verbalize the perineal care
proper necessary and hygiene
measures needed
to facilitate and
maintain proper
perineal care and
hygiene