Name : Mary Rose Guevarra Diagnosis: NSD/G1P1

Age : 19 y/o Problem: Acute pain

 Assessment Nursing Scientific Objectives Nursing Rationale Expected
Diagnosi Explanation Intervention Outcome
s

S= Acute Pain is an Short term:  Establish  To gain trust Short

O> patient manifested: Pain unpleasant After 4 rapport and quality term:
- verbal reports of sensation hours of exchange of The
8 in the pain ranging from nursing information patient
scale wild intervention,  Monitor vital  To obtain shall
- guarding discomfort to the patient signs baseline data have
behavior on the agonized will for future demons-
perineal area distress demonstrate reference Trated
- facial irritability associated use of  Assess  To evaluate use of re-
observed with real or relaxation patients deviations from Laxation
- capillary refill of poteantial skills and general normal findings skills and
3 sec. tissue diversional condition and to obtain diversio-
- Breast: no damage. activities as baseline data nal
tenderness Pain is a indicated for  To assess activities
noted response to individual  Note clients etiology and as
- Uterus: non- impulses situation. developmenta report pain indicated
tender upon from the l level parameters for
palpation peripheral affecting individ-
- Bladder: no nerves in the ability ual
distention damaged  Asses for  To help sitation.
- Bowel: no bowel tissue which referred pain determine
movement for 2 pass to as possibility of
days nerves in the appropriate underlying
- Lochia: rubra in spinal cord, condition or
minimal amount where they organ
- Episiorrhapy: are dysfunction Long
suture are subjected to requiring term:
intact; with no a gate Long term: treatment The
 Obtain
purupulent control. After 3 days patient
patients  To rule out
discharge Because of of nursing shall
asessment of worsening
- Skin: with good the patients intervention, have
pain to underlying
skin turgor presence of the patient Reported
include conditions of
- Homan sign: episorrhapy, will report Pain is
location, complications
negative the nerves pain is relieved
onset, quality,
- Emotional associated relieved From the
intensity,
status: Taking in with the from the score of 8
frequency,
- Provocation: tissue score of 8 in in the
intensity
with movement damage will the pain pain
 Use pain