NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC GOALS INTERVENTIONS RATIONALE EVALUATION

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

Dependent  reported absence

Prescribe To induce sleep of body malaise
sedatives as
ordered
References:
Fundamentals of
Nursing, 11th
edition