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

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.

Observed evidenced of pain.

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.

Pain is subjective experience and cannot be felt by others.

To determine deviations from normal and obtain subjective cues.

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

Sp. Gravity: 1.030 Glucose: negative Protein: negative pH: 6.5 y y y y Profused sweating Limited movement Restless

Verbalized feeling of comfort.

Provide adequate rest.

Verbalize of relief.

feeling

Perform cleansing bedbath to the patient.

Promotes feeling of rested, comfort and also avoid fatigue. 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. Medications ordered PRN basis should be offered to the client at the interval when the next dose is available..

The patient verbalized the feeling of comfort. The patient able to verbalize feeling of relief from cleansing bedbath. The client was able to take her prescribed medications.

y Facial Grimacing

On the given, administer pain reliever to the client.

Provide optimal pain relief with doctor s prescribed analgesics