ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION EVALUATION

DIAGNOSIS
S: “Ngayon Acute pain Episiorraphy After 30 Observe non- After 30
sumasakit related to repairing of minutes of verbal cues and minutes of
pwerta ko NSD by vulva by nursing pain behaviors nursing
lalo na kapag procedure suturing, intervention intervention
naglalakad at of episiorraphy the patient Provide or the patient
nakaupo” as episiorraphy is done to will be able promote non- was able to
verbalized by prevent to verbalize pharmacologica follow the
the patient more the l pain health
extensive decrease of management teaching
O: 8/10 pain vaginal tears pain from (Position taught by
scale during 8/10 to 3/10 change) the student
VITAL SIGNS childbirth or (proper nurses and
Rr 19 delivery and ambulation) was able to
Temp: 36 it heals verbalize the
Pr 72 better than Monitor vital decrease of
Bp 100/70 a natural signs pain from
LAB RESULTS tear. Also (Blood 8/10 to 3/10
URINLYSIS helps to pressure)
Color: preserve the (Respiratory
Yellowish muscular rate)
Transparency and (Temperature)
: connective (Pulse rate)
Slight hazy tissue
Lochia: Rubra support of Independent:
Discharge is the pelvic Monitor lochia
in red color floor discharge and
+ restless pads used every
+ facial day
grimace
+ Capillary Dependent:
refill 2 sec