Assessment Explanation of the Objectives Interventions Rationale Evaluation

Problem

P - Pain Episiotomy/Episiorraphy STO: After 2 hours of Dx: - Provides baseline

causes trauma to the skin nursing intervention, the - Evaluate pain noting information for
surface/layers and tissues patient will report characteristics, location, effectiveness of
S - “Nasakit dayto’y sugat which stimulates free decreased pain and intensity. interventions.
ko” nerve endings. sensations, with a pain
rating of not more than
There is increased blood 2/10. - Assess vital signs, - May indicate pain and
O - Episiorraphy site reddish flow to the wound as part noting tachycardia, discomfort.
and edematous of body’s LAS (function LTO: After 3 days of hypertension and
- Vital Sigs are as follows: laesa, rubor, calor, nursing intervention, the increased respiration.
BP - 130/90 tumor, and dolor). patient will report
PR - 110 absence of pain, appears - Assess causes of - Discomfort can be
RR - 26 relaxed, able to rest/sleep possible discomfort other caused/aggravated by the
T° - 37.2 °C and participate in ADL. than perineal wound. presence of catheters,
- Facial Masking NGT’s, IV lines, gastric
- With guarding behavior gas, and bladder pain.

Tx:
A – Acute Pain related to - Reposition patient - May relieve pain and
tissue trauma as evidenced by (Semi Fowler’s, Lateral enhance circulation
complaints of pain, facial Sim’s). relieves muscle tensions
grimacing and guarding and pressures.
behavior.
- Administer medication - Pain medication for
as prescribe. relief.

EDx:
- Encourage use of - Relieves muscle and
relaxation technique. e.g. emotional tension,
DBE enhances sense of control
and may improve coping
abilities.