Nursing Care Plan

Patient’s Name: XY Age: 26 y/o Diagnosis: NSVD

Assessment Nursing Inference Goals Interventions Rationale Evaluation

Diagnosis
Subjective: Disturbed Because of the pain Short Term Independent Short Term :
“di ako sleeping pattern at the perineum r/t After 3 hours of nursing • Position client • To alleviate After 3 hours of
makatulog kasi related to pain episioraphy, normal intervention, the client in a comfortable discomfort nursing intervention,
puro na lang and discomfort body relaxation is will: position the short term goal
sakit sa katawan on perineum hindered leading to • report decreased was met as
yung secondary to prolonged period of feeling of discomfort as • Provide • To distract evidenced by:
nararamdaman labor and time without sleep manifested by comfort attention on • Reported pain
ko” delivery or sleep deprivation verbalizing feeling of measures pain, reduce relief (5 out of
comfort (5 out of 10) (touch, quiet tension and to 10)
• Achieve at least 5-6 environment, promote • Pt was able to
Objective: hours of continuous dim light, light nonpharmacolo achieve 6
• 1hr of sleep sleep per day music) gical pain hours of
per day PTA • Show signs of management continuous
• 30 mins of decreased yawning at sleep that day
sleep per daytime • To provide • decreased
day upon • Report decreased • Assess sleep comparative yawning at
admission References: pattern baseline daytime
body malaise
• frequent Wikipedia: • reported
yawning at http://en.wikipedia. • To help in decreased
Expected Outcome
daytime org/wiki/Sleep • Provide a quiet providing better overall body
during Long Term and peaceful sleep/rest malaise
assessment After 3 days of nursing environment
• overall body intervention the client during sleep
malaise will: periods
• pain(8 out of • Be able to • Verbalizing Long Term
10) reestablish and • Encourage the concerns may After 3 days of
• dark circles maintain normal sleep client to express promote nursing intervention
around the pattern concerns when relaxation the short term goal
eyes • achieve 7-8 hours unable to sleep has been fully met as
of continuous sleep evidenced by:
per day • Provide a • Vasodilation of • reported
• report absence of warm bath the veins provide increased periods
body malaise before the client a sleepy, lazy of sleep of 8
• report further goes to sleep effect, causing continuous hours
alleviation of pain (3 the client to fall per day
out of 10) right to sleep
• absence of • Expose • absence of
frequent yawning perineum on • To provide frequent yawning
perilight bid for comfort
15 mins • established
sleep pattern

• reported pain
Dependent scale of 3 out of
• Prescribe 10
sedatives • To induce sleep
(Valium) as • reported
ordered absence of body
References: malaise
Fundamentals of
Nursing, 11th
edition