NURSING CARE PLAN (Mother – Post Partum)

Nursing Outcome Actual

Assessment Nursing Diagnosis Nursing Goal Rationale
Intervention Criteria Evaluation
Subjective: Acute Pain related to After 2-4 hours of Independent:
- “Medyo sakit Tissue Trauma comprehensive - Assess pain - Indicates need - Patient pain will
jud akong secondary to NSVD nursing reports, noting for/ effectiveness be reduced from
kinatawan, sir” interventions, location, pain of interventions a pain scale of 6
as verbalized by measures to scale, frequency and may signal to 0-1.
patient. alleviate pain will and onset. Note development of - Patient will
Scientific Basis: be implemented. nonverbal cues. complications. show signs of
Objective: Severe systemic comfort and
- Patient with manifestation of - Encourage - Efficacy of alleviation from
lumbar pain; Pain trauma and ischemia patient to report comfort pain
scale = 6 involving soft tissues, pain as it measures and - Patient will
- Discharges principally skeletal develops medications is verbalize that
present in muscle, due to improved with pain is relieved
vaginal area prolonged severe timely - Demonstrate
- Patient with crushing. It leads to - Encourage intervention use of relaxation
episiorrhapy increased verbalization of - Can reduce skills and
noted permeability of the feelings anxiety and fear diversion
- Patient at bed cell membrane and and thereby activities
rest most of the to the release of - Perform reduce
time noted potassium, enzymes, palliative perception of
and myoglobin from measures e.g. intensity of pain
within cells; which back massage, - Promotes
results in acute pain. repositioning relaxation/
(www.wrongdiagnosi decrease muscle
s.com/ Collaborative: tension
medical/tissue_traum - Administer
a.htm) analgesics,
narcotic
analgesic, or pain - Provide relief of
killers. Use pain and
Patient controlled discomfort. PCA
analgesia or medication keeps
provide around- the blood level of
the-clock analgesia stable,
analgesia with preventing cyclic
rescue doses PRN undermedication
 or
overmedication.

Reference: Nursing Care Plans; NCP CD-ROM