ASSESSMENT NURSING EXPLANATION GOAL AND INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OF THE OBJECTIVES

PROBLEM
Subjective: Acute pain related The client is STO: Dx: After the nursing
-‘Nasakit jay dait to disruption of experiencing the -After 3-6 hours of -Monitored the Vital - To establish a intervention, goals
ko ayanti tyan ko skin, tissue, and pain due to the nursing Signs baseline data met as evidence of
lalo no agkutkuti muscle integrity episiotomy done to intervention, the the clients
ak’ as verbalized. due to post her after the client’s pain will - Monitored elevated - To monitor decrease in pain
surgical incision. Caesarian Section be relieved or temperature, swelling, presence of signs scale from 7/10 to
-‘Nasa 7/10 ti operation. Pain is a controlled or if redness, or purulent of infections 2/10 and there is
sakit na’ as typical sensory not, pain will be drainage at incisions no facial grimace,
verbalized. experience that may lessened and the guarding behavior,
be described as the client will Tx: narrowed focus
Objective: unpleasant verbalize relief of -Assisted in a - May relieve pain and there is the
-Weak and pale in awareness of pain from 7/10 to comfortable position and enhance normalization of
appearance noxious stimulus or 3/10. circulation. vital signs, the
bodily harm. blood pressure to
-Presence of facial Individual LTO: - Prevents undue be specific.
grimace experiences pain by -After a day of - Identified specific strain on operative
various daily hurts nursing activity limitations site
-Guarding and aches, and intervention, the
behavior occasionally client will no - Improves
through more longer feel the -Provided additional circulation,
-Narrowed Focus serious injuries or pain as manifested comfort measures like reduces muscle
illnesses. by the absence of back rub tension and
VITAL SIGNS: facial grimace, anxiety related to
BP:130/90mmHg guarding behavior pain
PR:72bpm and narrowed
RR:22cpm focus.
T⁰:35.4⁰C
Edx: - Relieves muscle
- Encouraged use of and emotional
relaxation techniques tension.
like deep breathing
exercises. -Promotes
relaxation
-Encouraged deep
breathing exercise
- Antibiotics have
Collaborative: bactericidal effect
-Administer that combats
analgesics or no pathogens that
steroidal anti- relieves mild or
inflammatory moderate pain.
drugs as
Prescribed