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8•C P → 66 beats/min R → 14 breaths/ min BP→ 110/80 diaphoresis (+) pain face connotes pain Diagnosis: Few hr. PTA→ (+) lumbrosacral pain.
Nursing Analysis Pain r/t laceration of the delicate tissues AMB facial grimace. Impaired skin/ tissue integrity may be r/t mechanical interruption of skin/tissues, altered circulation, effects of medication, accumulation of drainage, and altered metabolic state, possibly evidenced by disruption of skin surface/ layers and tissues.
Planning/Objectives To be able to decrease the level of pain from 8 to 6 using pain scale of 10 to 1.
Intervention Instruct the pt. to take the medications on time.
Rationale To provide the pt. comfort if the pain has decreased from the pain scale goal. In order to heal or fast recovery after taking medications. To have comfort from the pain.
Evaluation Encourage to eat nutritious foods. Emphasized the importance of proper hygiene.
To provide comfort.
Positioned pt. comfortably. Linens stretched for more comfort.
Keep back dry.
V/S taken & be recorded.
To keep away from getting a disease such as pneumonia. To monitor if V/S has changed from its baseline and to assess the pt.’s condition.
Advised the mother to breastfeed.
Nrsg. Care rendered. discharged.