NURSING CARE PLAN

Nursing Care Plan Assessment Objective: -Pt vaginally delivered a live female -Pt has a perineal tear Nursing Diagnosis Acute Pain r/t childbearing, including perineal tear AEB clients verbalizations of pain Expected outcomes 1. Client will report no pain, or that pain management regimen reduces pain to a functional level before she is discharged. Interventions 1. a) Assess pain level in a client using a valid and reliable selfreport pain tool, such as the 0-10 numerical pain rating scale (0=no pain, 10= most pain possible). Rationale 1. a) Singledimension pain ratings are valid and reliable as measures of pain intensity level (Ackley & Ladwig, 2011, p. 601). Subjective: -Pt states they are experiencing pain 1. b) Assess the client for pain presence routinely at frequent intervals, at the same time as vitals are taken. 1. b) Pain assessment is as important as physiological vital signs and pain is considered the fifth vital sign (Ackley & Ladwig, 2011, p. 602). 1. c) Administer an opioid analgesic if indicated for moderate 1. c) Opioids are indicated for the Evaluation -Pt will report no pain or pain at a functional level during stay in hospital

NURSING CARE PLAN to severe pain as per doctors orders treatment of moderate to severe pain (Ackley & Ladwig, 2011, p. 603) 2. Client will express understanding of pain and pain management, including nonpharmacological methods of analgesia, and adverse effects of analgesics. 2. a) Manage acute pain using a multimodal approach 2. a) The advantage of a multimodal approach is that the lowest effective dose of each drug can be administered, resulting in fewer or less severe adverse effects (Ackley & Ladwig, 2011, p. 603). 2. b) Avoid giving pain medication intramuscularly (IM) when possible. 2. b) IM injections are painful, result on unreliable absorption, and lead to variable blood levels of the

-Client will articulate understanding of pain management before leaving the hospital

NURSING CARE PLAN administered medication (Ackley & Ladwig, 2011, p. 603). 2. c) Administer opioids orally or intravenously (IV). 2. c) IM injections are painful, result on unreliable absorption, and lead to variable blood levels of the administered medication (Ackley & Ladwig, 2011, p. 603). Deficient Knowledge r/t primipara status AEB client history 1. Client will state confidence in her ability to manage situation and remain in control of life before she is discharged. 1. a) Assess the client/family learning needs, information needs, and current level of knowledge. 1. a) Caregivers express a need for having their informational needs met (Ackley & Ladwig, 2011, p. 520).

Objective: -G1P0 Subjective: -Pt states that she is nervous that this is all really

-Client will feel confident in her ability to leave the hospital and care for the new baby

NURSING CARE PLAN happening now 1. b) Consider the clients ability and readiness to learn (e.g., mental acuity, ability to see and hear, existing pain, emotional readiness, motivation, and previous knowledge) when teaching clients. 1. b) Each client is unique, and client motivation, beliefs, and expectations will influence learning (Ackley & Ladwig, 2011, p. 518). 1. c) Engage clients as a partner in the educational process. 1. c) A nursing approach that is collaborative and that uses encouragement and support to increase self-efficacy resulted in client satisfaction, empowerment, and confidence (Ackley & Ladwig, 2011, p. 518).

NURSING CARE PLAN 2.Client will list resources that can be used for more information and support after discharge, before she is discharged. 2. a) Engage clients as a partner in the educational process. 2. a) A nursing approach that is collaborative and that uses encouragement and support to increase self-efficacy resulted in client satisfaction, empowerment, and confidence (Ackley & Ladwig, 2011, p. 518). 2. b) Use individualized approaches that support client priorities, preferences, and choice. 2. b) Individualized educational interventions have a positive effect on client outcomes (Ackley & Ladwig, 2011, p. 518). 3. c) Consider coordinated, multifaceted methods of 2. c) Coordinated efforts using a -Client will

articulate/show resources she can use to support her through life changes before she is discharged.

NURSING CARE PLAN disbursing information. combination of written and verbal information have proven beneficial for self-care behavioral change (Ackley & Ladwig, 2011, p. 518). Risk for Bleeding r/t childbearing AEB risk statistics 1.Pt will maintain stable vital signs with minimal blood loss both before and after her discharge. 1. a) Check vital signs at frequent intervals, according to AHS policy on 3A. 1. a) Watch for changes associated with bleeding including increased heart rate, respiratory rate, and eventually decreased blood pressure. (Ackley & Ladwig, 2011, p. 170). 1. b) Assess for clinical signs and symptoms of blood loss, such as 1. b). Blood loss is frequently

-Pts vital signs will remain stable -Pt will have minimal blood loss

NURSING CARE PLAN dizziness, fatigue, tachycardia, and hypotension. underestimated (500mL for vaginal delivery). (Ackley & Ladwig, 2011, p. 171). 1. c)Assess fundus and lochia amount regularly, according to AHS policy on 3A. 1. c)Vigorous massage and downward pressure should be avoided (Ackley & Ladwig, 2011, p. 171).

Ackley, B. J. & Ladwig, J. B. (2011). Nursing diagnosis handbook. An evidence based guide to planning care (9th ed.). St. Louis, MO: Mosby.