NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION
SUBJECTIVE: Risk for infection Contamination of a Long Term: Independent: Long Term:
related to presence of wound surface with After two days of • Change • To prevent After two days of
No Verbalization surgical wounds as microorganism thus interventions the perineal pads vaginal interventions the
evidenced by MER these colonization client will be able to frequently. contamination or client was able to
2nd degree has a complete new free from infection. infection. free from infection.
OBJECTIVE: cells for oxygen and
nutrition and because Short Term: • To promote Short Term:
• Presence of their by-products can After two hours of • Perform cleanliness to the After two hours of
perineal wounds interfere with a interventions the perineal care perineal area interventions the
due to healthy surface client will be able to: client was able to:
episiotomy condition that leads • Verbalize • To avoid edema • Verbalize
second degree to infection Health • Warm Health
• Not Teachings compressed may Teachings
practicing -Fundamentals of be applied to the
frequent Nursing by Kozier • Demonstrate genital area • Demonstrate
changing of page 910 at least 3 ways at least 3 ways
pads on how to Collaborative: • To aid healing of on how to
prevent • Sitz bath may the perineum prevent
infection. be ordered thorough infection.
application of
moist heat
LIST OF PRIORIIZED PROBLEM

Nursing Diagnosis Rank Justification

Pain related to damage on It is highly prioritized because based

muscle tissue as evidenced by 1 on the Maslow’s Hierarchy of Needs
episiotomy MER 2nd degree the physiologic needs of the patient is
greatly affected and need an
immediate action.

Constipation related to It is second prioritized problem

irregular defecation as 2 because based on the Maslow’s
evidenced by not defecating Hierarchy of Needs the physiologic
for 4-5 days. needs of the patient is affected and
need an immediate action.

Risk for infection related to It is third prioritized because based on

presence of surgical wounds 3 the Types of Nursing Diagnosis the
as evidenced by MER 2nd patient’s health is at “risk” and may
degree. likely happen.

Risk for falls related to It is fourth prioritized because based

absence of side rails 4 on the Types of Nursing Diagnosis the
secondary to not being raised. patient’s health is at “risk” and may
likely happen.

Health seeking behavior It is least prioritized because based on

related to precipitating 5 the Types of Nursing Diagnosis the
concern about the current patient’s health is at wellness state
health status as evidenced by
hospitalization