ASSESSMENT NURSING BACKGROUND GOALS OF CARE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE
Subjective: Acute pain Episiorraphy Within 1 hour of 1.Assess vital signs 1.Elevated blood pressure After 1 hour of nursing
“Sobrang sakit related to effects nursing especially her blood is usually observed. interventions the client’s
nung bandang of labor and done by interventions, pressure knowledge about
taas ng hita ko, delivery process the client will be minimizing the pain was
halos hindi ako as evidence by Suture able to gain 2.Obtain client 2.Observations may or able to met.
makalakad” as facial grimace and knowledge on assessment of pain may not be congruent
verbalized by the pain scale score causes how to including location, with verbal reports or
patient. of 8 out of 10 minimize the characteristic, onset, may be only indicators
Wound pain. frequency, quality, present when client is
Objective: intensity and unable to verbalized.
 Facial leads to precipitating factors.
Grimace Observe non-verbal
 Expressiv ACUTE PAIN cues
e
behaviou 3.Promote perineal 3. Tell the patient to
r exercise and ambulate as necessary.
(Uncomf comfortable sitting Before sitting squeeze
ortable position. buttocks together and sit
and within that position to
irritable) 4.Promotes positive reduce discomfort.
 Restlessn reinforcement and
ess encouragement to 4.The patient may fix her
 Pain patient. mind frame about the
Scale: pain, this in return will
8/10 lessen the perception of
VS: BP of 120/50 pain and anxiety.
 ASSESSMENT NURSING BACKGROUND GOALS OF CARE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE
Subjective: Risk for infection Wound Within 1 hour of 1.Assess general 1.To determine any After 1 hour nursing
“Meron po akong related to a site for Invasion of nursing condition deviations from interventions the
tahi sa ari ko, baka organism invasion as interventions the normal client was able to
magkaimpeksyon evidence by Pathogenic client will be able to 2.Assess skin for 2.The skin is the verbalize different
ito” as verbalized by presence of perineal Organisms verbalize different severity of skin body’s first line of ways on how to
the patient. wounds due to Leads to ways on how to integrity defense against prevent infection.
episiorrhapy. prevent infection. compromise. infection. Disruption
Objective: Bacterial Growth of the integrity of
 Presence of skin increases the
perineal Colonization patient’s risk of
wounds due Causes developing an
to infection or of
episiorrhapy Infection scarring.
 WBC Count: 3. Maintain or teach 3.Aseptic technique
asepsis for dressing decreases the
 V/S taken as changes and wound changes of
follows: care transmitting or
-BP: 120/50 spreading
-T: 35.8 ⁰C pathogens to the
-PR: 96 bpm patient. Interrupting
-RR: 18 the transmission of
infection along the
chain of infection is
an effective way to
prevent infection.