Cue Subjective: namamaga ang ari ko tatlong araw na..

as verbalized by the patient

Problem Infection r/t disease process as manifested by pain and swelling of the duct:

Objective: T= 39C P= 84 R=16 BP= 100/70 (+) vaginal discharge from the cyst (+) swelling near the vaginal orifice WBC, segmenters, lymphocytes

Scientific Explanation Obstruction of the distal Bartholin's duct may result in the retention of secretions, with resultant dilation of the duct and formation of a cyst. The cyst may become infected, and an abscess may develop in the gland. A Bartholin's duct cyst does not necessarily have to be present before a gland abscess develops.

Planning After 8 hours of nursing interventions, the client will: - attain a lower temperature of 37.4 or below - verbalize understanding of causative factors - identify interventions & demonstrate techniques to prevent spread of infection

Interventions Independent: - Monitor signs

Rationale

Evaluation * No redness or anomalous discharge is present at bartholins gland: swelling decreased: temperature is within normal range.

vital -To have baseline data and to monitor progress

- Assess and record character, amount, and odor of discharge. - Prepare & assist in the soaking of the genital area in hot sitz bath.

-to monitor the treatment process

-Sitz bath adds comfort on the part of the patient and may aid in the healing process.

After 3 to 5 days of nursing interventions, the - Reinforce proper client will: perineal care & - achieve timely hygiene. healing by displaying ambulation with little or without any discomforts - be free from any infections - Encourage increased fluid intake and adequate rest. - Encourage a balanced diet, emphasizing

-appropriate selfcare of the perineum reduces the further bacterial invasion. Antiseptic feminine wash or clean warm water may be used. - to bolster the immune system

- to feed the immune system

proteins Dependent: - Administer antibiotics and analgesics as indicated by the physician. - Antibiotics are used to treat & prevent infections caused by susceptible pathogens in skin structure infections. Analgesics are pain relievers that may aid in patients condition.

Cue

Problem

Scientific Explanation Post-surgical pain is a complex response to tissue trauma during surgery that stimulates hypersensitivity of the central nervous system. The result is pain in areas not directly affected by the surgical procedure.

Planning

Interventions

Rationale

Evaluation

Subjective: masakit pa din yung tahi ko as verbalized by the client. Objective: VS as follows: T= 39C P= 84 R=16 BP= 100/70 (+) Guarding behavior over genital area (+) Irritability (+) Facial grimace (+) Pain scale 7 / 10

Acute pain related to postsurgical procedure

After 8 hours of nursing interventions, the patients level of pain will decrease from 7/10 to 5/10

-Monitor elevated temperature

-for signs of infection

-Position client in a comfortable position. -provide comfort measures (quiet environment)

-to alleviate discomfort

Goal met. After 8 hours of nursing intervention, patients level of pain decreased from 7/10 to 5/10

-to distract attention on pain, reduce tension and to promote nonpharmacological pain management -verbalizing concerns may promote relaxation

-encourage the client to express concerns when in pain

-assess for referred pain

-to determine possibility of underlying condition or organ dysfunction requiring treatment.

Cues Subjective: hindi ako makagalaw masyado gawa ng nakirot as verbalized by the client.

Problem Impaired physical mobility related to acute pain

Objective: (+) post-op wound @ exterior genital area (+) Facial Grimace (+) perceived weakness (+) perceived difficulty in ambulating (+) slowed movement

Scientific Explanation Following the Marsupialisation, there will be a breakage in the continuity of the skin which then will trigger the inflammation process, which will result to nerve ending compression which results to pain. By then, the client will experience limited range of motion, slowed movements and reluctance to attempt movement which will then lead to impaired physical mobility.

Goal

Intervention

Rationale

Evaluation

After 8 hrs of nursing Independent: interventions, the patient will be able to: - Evaluate clients actual and perceived Increase limitations and strength and severity of deficit function of in light of usual lower status. extremities. Move within range of - Encourage motion. PROM/ROM Perform exercises. activities of daily living with little or no difficulty. - Assist client in ambulating and doing activities of daily living (taking a bath, etc) - Move objects that the client uses often within the client's reach.

After 8 hours of nursing - provides interventions, the comparative baseline client was able to and information perform activities about needed of daily living with education or little difficulty and interventions move within range regarding quality of of motion. life - To help prevent stiffness, prevent deformities, and help keep joints flexible - So that the client will be able to perform activities of daily living with decreased difficulty. - Moving objects closer upon reach will conserve the client's energy and will decrease difficulty with ambulating. - to promote optimal level of function.

- Provide client with ample time to perform mobility related task.

Dependent: - Administer analgesics as indicated by the physician. - Analgesics / pain relievers will rid of pain of which is the cause of client's impaired physical mobility.