NURSING CARE PLAN
Patient’s Initials: De Guzman,L.T
Age & Gender: 33_Female
Birthdate: November 03, 1988
Chief Complaint: Dizziness and
Weakness
Name of Student Nurse:
Returban, Chesca M.
Admitting Diagnosis: Risk for infection
related to mediolateral episiotomy and
vaginal laceration
Level/Block/Group: 2BSN A1 - 4
Address: Cabanatuan City, Nueva Ecija
Hospital Area: Premier Medical
Center
Clinical Instructor: April Veajedor
ASSESSMENT
SUBJECTIVE:
•Dizziness and
weakness
•The patient was
somnolent and pale
NURSING
ANALYSIS
Due to low
hemoglobin and
platelet count, the
patient might
develop an infection
through the
laceration. The
patient feels
weakness,dizziness,
somnolent and pale
PLANNING
SHORT
TERM
GOALS:
After 8 hour
shift of
preventative
intervention,
the client will
be able to:
INTERVENTIONS
RATIONALE
EVALUATION
INDEPENDENT:
1.Assess the
patient’s
knowledge on how
to do a proper care
of the sutured
mediolateral
episiotomy.
1.The patient’s
knowledge is not
enough on how to
do a proper care of
the wound. It really
needs to educate
the patient for her to
gain more
knowledge.
GOAL MET:
-The patient maintain
a normal blood
pressure.
OBJECTIVE:
P= 108 bpm
BP= 60/40 mmHg
Laboratory Data:
Hemoglobin: 9.6 g/dl
WBC count:
28.2x/109/L
Platelet count:
153x109/L
due to low blood
pressure and
hemoglobin count.
1.Make her
hemoglobin to
a normal level.
2.Impart
knowledge to
a client on
how to make
her blood
pressure and
hemoglobin
will become
normal
Transvaginal
ultrasound revealed a
9- mm-thick regular
endometrium and
normal ovaries
bilaterally.
3.Help the
client to
recover from
the delivery.
No vaginal masses or
hematoma. The
uterus was in tonic
contraction.
LONG TERM
GOALS:
After a month
shift of
preventative
intervention,
the client will
be able to:
1.The client
will become
knowledgeabl
e on how to
2.Educate the
patient along with
the family on
preventative
measures when
vaginal bleeding
occurs.
3. Impart
knowledge to the
family on how to
clean the
laceration
properly.
2.Educating the
family will help the
patient for a fast
recovery.
2.Follow up checkup.
-The patient make
her hemoglobin to a
normal level
GOAL MET:
3.Imparting
knowledge will help
them incase the
situation will happen
again.
DEPENDENT
1.Administer
medications as
prescribed by the
physician.
GOAL MET:
1.Medications
prescribed by the
physician is
important to
administer the
patient the right
medicine for her.
2 .Follow up checkup will help the
patient to know if the
wound is completely
cured. It will also
help to improve the
patient for her
recovery.
-The patient and the
family is
knowledgeable on
how to do a proper
perineal care.
GOAL MET:
-The patient is slowly
recovered from the
delivery.
do a proper
perineal care.