Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Short term Goal: Independent: Short term

“Mahapdi po After 1 hour of  Investigate  Self-report Goal
outcome:
itong tinahian nursing intervention reports of pain, should be the
Goals are met.
sakin pag umiihi Pain related to the client will: noting location primary source of After 1 hour
ako” surgical incision -Report satisfactory and intensity pain assessment of nursing
intervention,
as verbalized by as evidenced by pain control at a (using 0- in determining
the client:
the client. reports of pain, level less than 3 to 4 10/similar scale). pain -Reported
grimaced face, on a scale of 0-10 Note precipitating management satisfactory
pain control at
discomfort in -Exhibit increased factors and needs and
a level of 3 on
Pain Scale: 5/10 surgical area comfort such as nonverbal pain effectiveness of a scale of 0-10
and altered gait. relaxed facial cues. program. -Exhibited
increased
expression.  Observe or  Some people comfort such
Objective Data: monitor signs and deny the as relaxed
facial
-grimace when symptoms experience of expression.
moving associated with pain when it is
-altered gait pain. present.
-Vital signs are Attention to
as follows: associated signs
BP-110/70 may help the Long term
Goal
mmHg nurse in
outcome:
RR-20 cpm evaluating pain. Goals are met.
PR-80 bpm Long term Goal:  Encourage the  To provide After 1 day of
T- 37.0 degree After 1 day of client to apply comfort, reduce nursing
celcius nursing intervention warm, dry heat in edema, and intervention
the client will be the form of a promote healing. the client was
able to move and perineal hot pack Yet, healing able to move
urinate without an or moist heat with increases best if and urinate
increase in pain a sitz bath. circulation to the without an
level, and display a perineal area is increase in
relaxed manner. encouraged by pain level,
the use of heat. and display a
 Advise client to  Prevents relaxed
use a washcloth possible burn to manner.
or gauze square the area.
between the pack
and their skin.
 Advise the client  Moisture harbors
to keep the area microorganisms
clean and dry. that could result
to infection.
 Inform the client  The perineal area
that the pain or heals rapidly.
discomfort is
normal and does
 not usually last
longer than 5 or 6
days.
 Explain to the  To relieve anxiety
client that sutures as client may
are not need to be worry that she will
removed. experience
additional
discomfort when
the episiotomy
sutures are
removed. Sutures
are made of an
absorbable
material and it
usually dissolve
within 10 days.
Dependent:
 Given to reduce
 Administer
pain.
analgesic as
ordered.
Interdependent:
  Monitor  To determine
hematologic test presence of
and other pertinent infection and
laboratory records other
complications
related to
pregnancy and
giving birth.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Short term Goal: Independent: Short term Goal
“Namamaga ‘tong After 1 hour of  Establish To assess outcome:
dalawang paa ko Fluid volume nursing rapport precipitating and Goals are met.
simula pa nung excess related to intervention the causative After 1 hour of

malapit na akong hormonal client will factors nursing

manganak” imbalances as verbalize  Review the Such intervention the

evidenced by understanding of patient’s information can client verbalized

swollen left and the measures to history to assist to direct understanding of

right legs and prevent and determine the management. the measures to

Objective Data decreased lessen fluid probable History may prevent and

-Both legs are hemoglobin and volume excess cause of the include lessen fluid

swollen hematocrit level complications fluid increased fluids volume excess

-muscle secondary to such as imbalance. or sodium complications

tenderness on pregnancy. inflammation of intake. Yet, such as
both legs both legs. excess fluid inflammation of
-restlessness volume is a both legs.
-Vital signs are as normal
follows: occurrence of
BP-110/70 mmHg
pregnancy as
RR-20 cpm
long as
PR-80 bpm
proteinuria and
T- 37.0 degree
hypertension
celcius
are absent.
Long term Goal:  Assess and Edema occurs
After 1 day of monitor the when fluid Long term Goal
nursing location and accumulates in outcome:
intervention the extent of the Goals are met.
client will display a edema. extravascular After 1 day of
relaxed manner. spaces. nursing
Dependent intervention the
areas more client displayed a
readily exhibit relaxed manner.
signs of edema
formation.
Edema is
 graded from
trace (indicating
barely
perceptible) to 4
(severe edema).
 Advise client to This position
rest in a left increases the
side-lying kidney’s
position. glomerular
filtration rate
and allows for
good venous
return.
 Encourage Allows for good
client to sit for venous return.
half an hour in
the afternoon
and again in
the evening
with the legs
elevated.
 Advise the  These impede
 client to avoid lower
wearing extremities
constricting circulation and
clothing such venous return.
as panty
girdles or knee
high stockings.
 Educate  Information is
patient and key to
family managing
members problems.
regarding fluid
volume excess
and its relation
with
pregnancy.

Dependent:
 Monitor BP,  Deviations may
HR, and RR. indicate a need
for medication
and close
 monitoring.
Interdependent:
 . Monitor  To determine
any deviations
hematologic
that need
test and other prompt action.
pertinent
laboratory
records

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Disturb sleep Short term: -Establish rapport -To promote Goal met.
“Paputol-putol ang pattern related to After three hours cooperation Patient states that
tulog ko lalo na’t exhaustion from of nursing -Monitor and -To have a she is able to
dalawa ang and excitement of interventions the record vital signs baseline data, sleep and feels
inaalagaan ko” as childbirth patient will assess changes in rested during
verbalized by the verbalized of patient’s pattern of postpartal period.
client feeling rested and sleep The patient
Objective Data: improved sleeping -Recommend -Asking for a recovered easily
-presence of pattern. support person to support person from the sleep
eyebags Long term: relieve her after after disturbance with a
-weakness and After one day of breastfeeding breastfeeding collaboration of
restlessness nursing promote adequate the support
-yawning interventions the rest for the mother person.
-BP: 110/70 patient will
-Temp: 37 achieve optimal
-PR: 80 bpm amount of sleep,
-RR: 20 bpm decrease the
presence of
eyebags, and
absence of
restlessness