Assessment Subjective: “ Sumasakit ang tahi ko”, as verbalized by the pt. Objective:  conscious and cooperative V/S T → 36.

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.

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