CUES/EVIDENCES Subjectives: Client verbalized that y sakit ang akong tahi usahay y mag ngut-ngot pud

usahay ang akong tahi

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION At the end of our care all objectives were partially met as evidenced by:

Altered comfort: acute Within our 2 days of pain related to surgical nursing care the patient incision secondary to will be able to: episiotomy wound. y Vital signs in normal range T= 36.5 C-37.5 C P=60-100bpm R=15-20cpm BP=110-140/6090 mmHg y Monitor patients vital signs. y To obtain baseline data

y

Objectives: y VITAL SIGNS T: 36.5 C R: 17 cpm P: 75 bpm BP: 120/85 mmHg y Client rate the pain 4 (1 lowest10 highest)

Vitals signs: T=37.1 C, warm to touch. P=73 bpm, regular R=23 cpm, no use of accessory muscles. The patient was able to observed evidence of pain.

y

Observed evidenced of pain.

y

y y LABORATORY RESULT URINALYSIS Color: yellow Transparency: slight hazy y Patient report of less pain. y

Accepts clients percerption of pain. Acknowledge the pain experience and convey acceptance of clients response of pain. Assess patient s general health condition.

y

Pain is subjective experience and cannot be felt by others.

y

y

To determine deviations from normal and obtain subjective cues.

y

The patient reports less pain especially when she takes her medication.

The patient able to verbalize feeling of relief from cleansing bedbath.030 Glucose: negative Protein: negative pH: 6. To cleanse the body and feeling of relief also to reduce the risk of infection. Each client has a right to expect maximum pain relief. Gravity: 1. y The patient verbalized the feeling of comfort. Medications ordered PRN basis should be offered to the client at the interval when the next dose is available. comfort and also avoid fatigue.Sp. y y Facial Grimacing On the given. y Promotes feeling of rested.5 y y y y Profused sweating Limited movement Restless y Verbalized feeling of comfort. y Provide optimal pain relief with doctor s prescribed analgesics y y . administer pain reliever to the client. feeling y Perform cleansing bedbath to the patient. y y Verbalize of relief. The client was able to take her prescribed medications.. y Provide adequate rest.

Sign up to vote on this title
UsefulNot useful