Name of Patient: JVP ___________________________________________________________ Room Number: 206__________________________________________

Agency: Bishop Joseph Regan Memorial Hospital______________________________ Diagnosis:_____________________________________________

Date and Time Cues Need Nursing Diagnosis Objective of Care Nursing Intervention Evaluation
December 9, 2019 Subjective P Pain related to uterine After 4 hours of Independent After 4 hours of nursing
“sobrang sakit H cramping and perineal suture nursing intervention 1. Promote perineal exercise and intervention the patient
kasi nung sa Y as manifested by pain scale of the patient will comfortable sitting position such was able to experience
tiyan ko saka sa S 7/10 and grimace and experience lesser pain as: lesser pain and above a
tahi ko” as I irritability. and above a tolerable  To decrease discomfort tolerable level as
verbalized by O level as manifested by: manifested by:
the patient L - Kegel’s exercise
Objective O Oxytocin was released to -Pain scale of at least  Three or four times a day  Pain scale 4/10
-Pain scale of G contract the uterus to 5/10 with five times succession  No facial grimace
7/10 I decrease bleeding and causes -No facial grimace reduces discomforts and  Calm and
-sweating C contraction of the uterine -slight irritability and improves circulation in the cooperative
-facial grimace cramps. Under a great deal of most of the time is area and decrease edema.
-irritability N pressure during delivery, calm Therefore the goal was
-discomfort E perineum responds by the - Sitting position met.
E development of edema and  Before sitting squeeze
D generalized tenderness buttocks together and sit
following delivery. And the with that position reduces
P episiotomy incisions. physical discomfort.
A
I 2. Tell patient that the pain and
N (Kozier & Erb’s discomforts usually last more
A Fundamentals of Nursing than 3 days
V 10th Edition) - So that the patient may fix her
O mind frame about the pain, this in
I return will lessen the perception
D of pain and anxiety.
A
N 3. Instruct patient to do breathing
C exercises
E - Facilitates relaxation

Maslow’s Dependent
Hierarchy 1. Administer analgesic as
of Needs ordered by physician
- To relieve the pain

Name of Student: ______________________________________