Assessment Nursing Analysis Planning/Objectives Intervention Rationale Evaluation

Subjective: Pain r/t laceration  To be able to  Instruct the pt.  To provide the  Encourage to
“ Sumasakit ang of the delicate decrease the level of to take the pt. comfort if the eat nutritious
tahi ko”, as tissues AMB facial pain from 8 to 6 medications on pain has foods.
verbalized by the grimace. using pain scale of 10 time. decreased from  Emphasized the
pt. to 1. the pain scale goal. importance of
Impaired skin/  In order to heal proper hygiene.
Objective: tissue integrity or fast recovery
 conscious and may be r/t after taking
cooperative mechanical medications.
V/S interruption of  To provide  Positioned pt.
T → 36. 8•C skin/tissues, comfort. comfortably. To have comfort
P → 66 beats/min altered  Linens from the pain.
R → 14 breaths/ circulation, stretched for
min effects of more comfort.
BP→ 110/80 medication,
 diaphoresis accumulation of  Advised the
 (+) pain drainage, and  Keep back dry.  To keep away mother to
 face connotes altered metabolic from getting a breastfeed.
pain state, possibly disease such as
evidenced by  V/S taken & be pneumonia.
Diagnosis: disruption of skin recorded.  To monitor if
 Few hr. PTA→ surface/ layers V/S has changed
(+) lumbrosacral and tissues. from its baseline  Nrsg. Care
pain. and to assess the rendered.
pt.’s condition.  discharged.