ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS BACKGROUN INTERVENTIONS

D
Subjective: Acute pain Episiotomy After 6 hours  Provide  To gain After 6 hours of
“medyo related to of nursing care, the rapport with trust and nursing care, goal
sumasakit parin surgical client will be able to: the patient. full was met as
yung tahi ko incision cooperation manifested:
.” As verbalized (episiotomy) Complexity of  Express during the  Expressed
by the patient. secondary the procedure alleviation of  Monitor vital alleviation of
to normal pain from scale signs. pain from
Objective: spontaneous of 4 to 2 pain scale from 4-
-facial grimace delivery as Increased risk 2
alleviation
-pain scale of evidenced for being  To know different  Adequate rest  Client knew
periods.
4/10 by facial invaded by techniques in and sleep. different
grimacing. pathogenic alleviating pain techniques in
 Vital signs
VS taken as organisms  Provide a alleviating
altered
follows:  Comfortably fall therapeutic pain.
during acute
Temp: 36.4 asleep environment  Comfortably
pain.
RR: 21 breaths . fell asleep
per min Lacerations
PR: 93 bpm and broken  Encourage  To assess in
BP:120/70 skin destroy verbalization alleviation
mmHg the body’s of feelings. of pain.
O2 Saturation: first line of
96% defense, the
skin.  To aid in
alleviation
of pain.
Acute Pain

 To assist in
evaluation.

SUBMITTED BY: SUBMITTED TO:

DIANA R. GOROSPE FRITCHY P. FORNEAS, MAN
BSN 2-D CLINICAL INSTRUCTOR