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