Assessment Nursing Inference Goal Intervention Rationale Evaluation

Diagnosis
SUBJECTIVE: disruption of skin, LONGTERM: INDEPENDENT:
“ kumikirot ang tahi ko lalo Acute pain tissue and muscle After 3 days of nursing  Monitor vital  To have baseline After 3 days of nursing
na kapag gumagalaw” as related to integrity intervention the client signs data and to intervention the client
verbalized by the client disruption of will report absence of monitor progress reported absence of
skin, tissue pain as manifested by: of treatment pain as manifested by:
OBJECTIVE: and muscle damage nerve
integrity ending  promote perineal  Reduce
 Pain scale of 6/10 secondary to  pain scale of exercise (kegel’s discomfort and  pain scale of
episiorraphy 0/10 after 2 exercise)and improve 0/10 after 2
 Facial grimace localized pain days comfortable circulation in the days
noted when stimuli sitting position perineum area
changing position  no facial  no facial
grimace when  instruct patient  Relax skeletal grimace when
 Slow movements converted to moving after 2 to do deep muscle thus moving after 2
noted when walking electrical signal by days breathing reducing tension days
nociceptor exercise
 Seeking out her her  can move  moved freely
husband when freely without  schedule  Prevent fatigue without
going to the travel to brain assistance after adequate rest and conserve assistance after
restroom 3 days periods energy 3 days

 Discomfort activation of  exhibit  review  Provide elements  exhibited

chemical such as comfortable importance of necessary for comfortable
 Reddish and bradykinin, appearance nutrition diet and tissue appearance
inflamed prostaglandin after 2 days adequate fluid regeneration and after 2 days
episiorraphy site intake healing
SHORTERM: SHORTERM:
chemicals released After 8 hours of nursing  apply cold pack  Lessen redness After 8 hours of nursing
and reaction occur intervention, the client on the perinuem and inflammation intervention, the client
will exhibit decrease area for 24 hours exhibited decrease
pain on incision site feeling of pain as followed by hot feeling of pain as
manifested by: pack (cold and manifested by:
 hot therapy)
 from pain scale  Promote healing  from pain scale
of 6/10 to pain  provide perilight of 6/10 to pain
scale of 4/10 x 15mins BID scale of 4/10
after 30  Prevent tension after 30
minutes  encourage minutes
verbalization of
 lessen redness feelings  lessened
and  For good quality redness and
inflammation  provide quiet of rest inflammation of
of episiorraphy and calm episiorraphy
site after 8 environment site was seen
hours  Prevent focusing after 8 hours
 encourage on pain
diversional
activities
(music/TV,
socializing)

DEPENDENT:
 To relieve mild
 Administer and moderate
Mefenamic Acid pain
(Ponstan SF)
500mg/cap TID
PO
REFERENCE: REFERENCE:
Kozier & Erb’s Maternal and Child
Fundamentals of Health Nursing Vol.1 6th
Nursing 8th edition edition Page 430
Page 1193