ASSESSMENT NURSING DIAGNOSIS CLIENT GOAL OUTCOME NURSING RATIONALE ACTUAL

CRITERIA INTERVENTIONS EVALUATION

SUBJECTIVE SCIENTIFIC BASIS: After 5 hours Patient Independent: At the end of

CUES: Acute pain related to surgical of nursing remain to be nursing care
“Sakit ang incision secondary to median care, the in comfort as -Encourage the This helps to plan, the goal
akoang tahi sa episiotomy. patient will be evidenced by patient in semi- produce was met as
akong ubos able to absence of fowler’s position comfort to the evidenced by
dapit nya mag experience signs of pain patient that the patient
ngot-ngot” As alleviate the reported that
verbalized by pain Patient will -Instruct the Helps focuses the pain has
the patient remain patient to do on client’s been alleviate.
afebrile relaxation attention, The patient
without any techniques in promotes verbalized that
OBJECTIVE complain of providing activities positive she felt relieve
CUES any pain. like watching TV or attitude, and and felt
read books. aid comfort. comfortable and
-Present with REFERENCE: was able to take
facial grimace https://nurseslabs.com/puerperal- -Instruct the This would help prescribed
infection-nursing-care-plans/ patient to do sitz ease the pain, medications.
-Pain scale of bath promote
6/10 Doenges, M. E., Moorhouse, M.F., healing, and
Murr, A.C. (2012). Nursing Care give good
-Restlessness Plans: Guidelines for hygiene to the
Individualizing Client Care Across perineal area
-Limited the Life Span. F.A. Davis Company
movement

-Sweating

-Accept the Pain is

perception’s client subjective
of pain. experience and
Acknowledge the cannot be felt
pain experience by others.
and express
acceptance of
clients response of
pain.

-Encourage the This provides

patient to do bed the feeling of
rest. rested, comfort
and also help to