Scribd Logo
Upload

Welcome to Scribd!

  • Assessment Nursing Diagnosis Background Knowledge Goals of Care Intervention Rationale Evaluation Subjective: Episiorraphy

    Uploaded by

    Maria Jessica Dumdum
    48 views2 pages
    The nursing note summarizes the care provided to a client experiencing acute pain after an episiorrhaphy. The goals were to educate the client on minimizing pain and preventing infection within 1 hour. Interventions included assessing vital signs and the wound, teaching proper perineal care, and promoting exercise. The client's knowledge about pain management and prevention of infection was evaluated as met after nursing interventions.

    Original Description:

    Original Title

    ASSESSMEN1

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    The nursing note summarizes the care provided to a client experiencing acute pain after an episiorrhaphy. The goals were to educate the client on minimizing pain and preventing infection within 1 hour. Interventions included assessing vital signs and the wound, teaching proper perineal care, and promoting exercise. The client's knowledge about pain management and prevention of infection was evaluated as met after nursing interventions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    48 views2 pages

    Assessment Nursing Diagnosis Background Knowledge Goals of Care Intervention Rationale Evaluation Subjective: Episiorraphy

    Uploaded by

    Maria Jessica Dumdum
    The nursing note summarizes the care provided to a client experiencing acute pain after an episiorrhaphy. The goals were to educate the client on minimizing pain and preventing infection within 1 hour. Interventions included assessing vital signs and the wound, teaching proper perineal care, and promoting exercise. The client's knowledge about pain management and prevention of infection was evaluated as met after nursing interventions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    ASSESSMENT NURSING BACKGROUND GOALS OF CARE INTERVENTION RATIONALE EVALUATION

    DIAGNOSIS KNOWLEDGE
    Subjective: Acute pain Episiorraphy Within 1 hour of 1.Assess vital signs 1.Elevated blood pressure After 1 hour of nursing
    “Masakit yung related to effects nursing especially her blood is usually observed. interventions the client’s
    tahi sakin sa ari of labor and done by interventions, pressure knowledge about
    ko, pano ba delivery process the client will minimizing the pain was
    mawala yung as evidence by Suture gain knowledge 2.Obtain client 2.Observations may or met.
    sakit?” as facial grimace and on how to assessment of pain may not be congruent
    verbalized by the pain scale score causes minimize the including location, with verbal reports or
    patient. of 6 out of 10 pain. characteristic, onset, may be only indicators
    Wound frequency, quality, present when client is
    Objective: intensity and unable to verbalized.
     Facial leads to precipitating factors.
    Grimace Observe non-verbal
     Expressiv ACUTE PAIN cues
    e
    behaviou 3.Promote perineal 3. Tell the patient to
    r exercise and ambulate as necessary.
    (Uncomf comfortable sitting Before sitting squeeze
    ortable position. buttocks together and sit
    and within that position to
    irritable) 4.Promotes positive reduce discomfort.
     Restlessn reinforcement and
    ess encouragement to 4.The patient may fix her
     Pain patient. mind frame about the
    Scale: pain, this in return will
    6/10 lessen the perception of
    VS: BP of 120/90 pain and anxiety.
    ASSESSMENT NURSING BACKGROUND GOALS OF CARE INTERVENTION RATIONALE EVALUATION
    DIAGNOSIS KNOWLEDGE
    Subjective: Risk for infection Wound Within 1 hour of 1.Assess general 1.To determine any After 1 hour nursing
    “Pano kung related to Invasion of nursing condition deviations from interventions the
    nagkaimpeksyon knowledge deficit. interventions the normal client was able to
    yung sugat ko sa ari Pathogenic client will be able to 2.Assess skin for 2.The skin is the verbalize different
    ko? Ano gagawin ko Organisms verbalize different severity of skin body’s first line of ways on how to
    para maiwasan?” as Leads to ways on how to integrity defense against prevent infection.
    verbalized by the prevent infection. compromise. infection. Disruption
    patient. Bacterial Growth of the integrity of
    skin increases the
    Objective: Colonization patient’s risk of
     Presence of Causes developing an
    perineal infection or of
    wounds due Infection scarring.
    to 3. Maintain or teach 3.Aseptic technique
    episiorrhapy asepsis for dressing decreases the
     WBC Count: changes and wound changes of
    care transmitting or
     V/S taken as spreading
    follows: pathogens to the
    -BP: 120/90 patient. Interrupting
    -T: 36.8 ⁰C the transmission of
    -PR: 92 bpm infection along the
    -RR: 15 chain of infection is
    an effective way to
    prevent infection.

    You might also like