NURSING CARE PLAN

Identified Problem: Postpartum blues

Nursing Diagnosis: risk for impaired parenting related to insufficient social support as manifested by a low self-esteem

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Independent Short term:
1.) Goal met after 4 hours of
 “gang di man ko sure if  After 4 hours of 1.) Establish rapport - Establishes rapport, nursing interventions
ready nako mag atiman providing nursing 2.) Be available to the client for listening and promotes expression of patient is reporting
ug bata” as verbalized interventions patient talking feelings manageable anxiety
by the patient will be able to report 3.) Encourage verbalization of feelings - Validates reality of feelings,
anxiety control as 4.) Acknowledge anxiety neither denying or false reassurance may be
evidenced by reassuring client that everything will be interpreted as lack of
1. Decrease in reports alright understanding or
of fear and anxiety 5.) Assess parent/child interactions dishonesty
2. Freely expressing 6.) Assess parenting skill level - Identifying the way in which
concerns and 7.) Evaluate parents’ ability to provide the family responds to one
possible solutions protective environment and participate in another is crucial in
about parenting a reciprocal relationship determining the need for
roles 8.) Providing comfort measures and type of interventions
Objective: 9.) Encourage awareness of negative self- required
talk and discuss replacing with positive - Identifies areas of need for
 Restlessness noted statements further education, and skill
 Patient has a training.
BP – 140/90mmHg - The ways in which the
RR – 21cpm Dependent parent responds to the
HR – 127bpm 1.) Instruct the patient in the appropriate use child are critical to the
T – 36.8C Long term objectives: of antianxiety medications prescribed by child’s development, and
attending physician interventions need to be
 After 8 hours of directed at helping the Long term:
providing nursing parents to deal with their 1.) Goal met after 8 hours of
interventions the own issues and learn nursing intervention
patient will be able to Collaborative positive parenting skills patient is able to exhibit
exhibit nurturing and  Refer to psychiatrist - Aids in meeting basic nurturing and protective
protective behaviors human need, decreasing behaviors toward child
toward child sense of isolation
- Limits degree of stress and
avoids overwhelming
anxious adult

- To apply interventions
related to mental health

Patient’s Name / Room No. | 1

 NURSING CARE PLAN
Identified Problem: acute pain in perineal area

Nursing Diagnosis: acute pain related to episiotomy

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Independent - To gain patient cooperation Short term:
 “sakit pag mulihok” as 1.) Establish rapport and trust - Goal met after 4 hours of
verbalized by the  After 4 hours of 2.) Monitor vital signs - To acquire baseline data nursing interventions
patient nursing 3.) Provide measures to relieve pain before - It is preferable to provide patient reports tolerable
 Patient reports a pain interventions patient it becomes severe. an analgesic before the pain
of 8 out of 10 in the will be able to report 4.) Note location of surgical incision onset of pain or before it - Patient reports a pain
pain assessment pain is relieved or 5.) Assess for referred pain, as appropriate becomes severe when a scale of 4 out of 10
scale controlled 6.) Provide nonpharmacologic pain larger dose may be - Patient vital signs
 After 4 hours of management, such as implementing a required. - RR - 21 cpm
nursing intervention sitz bath - This can influence the - HR - 98 bpm
patient will be able to 7.) Use of relaxation exercises amount of postoperative - BP – 120/80
report a pain scale of 8.) Identifying ways to avoid or minimize pain experienced - T – 36.8 C
3 or lower out of 10 pain. - Help determine possibility
of underlying condition or
Dependent organ dysfunction
1.) Give analgesics as prescribed by - These methods are used to
physician provide comfort by altering
Objective: psychological responses to
 Patient is noted to be Collaborative pain.
restless 1.) Collaborate with medical providers in - Exercise to alleviate pain
 Patient is observed pain assessment including neurological - Keeping body in good
grimacing and psychological factors as appropriate alignment and using proper
 Patient is observed to when pain persists body mechanics to alleviate
be diaphoretic Long term objectives: pain
 Patient has an  After 8 hours of - To maintain “acceptable”
nursing levels of pain
HR - 127 bpm interventions patient ` Long term:
RR - 30 cpm will be able to report - Goal met after 8 hours of
BP - 130/90mmHg absence of pain in nursing interventions
T - 37.8 C perineal area and patient reports absence
of pain
- Patient vital signs
RR - 19 cpm
HR - 89 bpm
BP – 120/80
T – 36.8 C

Patient’s Name / Room No. | 2

 NURSING CARE PLAN
Identified Problem: Risk for infection

Nursing Diagnosis: Risk for infection related to episiotomy

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Independent Short term:
 “kahilantanon man ko - Gains patient cooperation - Outcome met after 4
gang” as verbalized by  After 4 hours of 1.) Establish rapport and trust hours of nursing
the patient providing nursing 2.) Practice and emphasize constant and - First line defense against interventions patient is
” interventions patient proper hand hygiene to minimize healthcare-associated able to verbalize
will be able to contaminations - Utilizing the environment of understanding of
verbalize 3.) Provide clean and well-ventilated the patient to assist him in individual causative or
understanding of environment his recovery risk factors, and patient is
individual causative 4.) Emphasize proper use of personal - For particular exposure able to identify
risk factors. protective equipment risks interventions to prevent
And patient will be 5.) Change surgical or other wound - To prevent contamination or reduce risk of
able to initiate dressings, as indicated using proper - Inappropriate use could infections.
behaviors to limit technique for changing/disposing of lead to development of
the spread of contaminated material drug-resistant strains or
Objective: infection, as 6.) Cover perineal and pelvic region secondary infections
 Patient is noted to be appropriate, and dressings or cast with plastic when using Long term:
feverish as evidence reduce the risk of bedpan - Outcome met after 8
by a Temperature of complications. 7.) Discuss the importance of not taking - To determine effectiveness hours of providing nursing
37.8C antibiotics or using “leftover” drugs of therapy or presence of interventions patient is
 Patient noted to be unless specifically instructed by side effects able to demonstrate
restless healthcare provider techniques and lifestyle
 Patient has a Long term objectives: - For additional and changes to promote a
BP – 130/90mmHg 1. After 8 hours of Dependent specialized treatment safe environment and
RR – 22cpm providing nursing 1.) Administer/monitor medication regimen is able to achieve timely
PR – 124bmp interventions patient 2.) Administer prophylactic antibiotics and wound healing; free of
will achieve timely immunizations as prescribed purulent drainage or
healing, free of erythema, and is afebrile
additional Collaborative
complications. 1.) Encouraging contact with primary
healthcare provider for prophylactic
therapies, as indicated

Patient’s Name / Room No. | 3

Patient’s Name / Room No. | 4