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.

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

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