ACTUAL NCP Cues Subjective: sumasakit yung tahi paminsan minsan. as verbalized by the client.

Objective: -facial grimace -pain scale of 6 -slowed movement V/S taken as follows: Temp: 37.3 Rr: 21 Pr: 81 BP:120/70 Nursing Diagnosis Acute vaginal pain related to right medio lateral episiotomy as evidenced by facial grimacing. Planning After 8 hours of nursing care, the client will be able to: -express alleviation of pain from scale of 6 to 2 -to know different techniques in alleviating pain -comfortably fall asleep Nursing Interventions -Provide rapport with the patient Rationale -To gain trust and full cooperation during the pain alleviation periods -Vital signs altered during acute pain -To aid in alleviation of pain -To assist in evaluation -To alleviate pain Evaluation After 8 hours of nursing care, the client: - expressed alleviation of pain from scale of 6 to 3 -knew different techniques in alleviating pain -comfortably fell asleep

-Monitor vital signs -Provide a therapeutic environment -Encourage verbalization of feelings -Encourage to do diversional activities -Encourage rest and sleep

-To assess in alleviation of pain

POTENTIAL NCP Cues Objective: -NSD with episiotomy -used single pad for 12 hours -Temp. = 37 C -identify interventions and demonstrate techniques to prevent risk for infection -Emphasized early ambulation and beginning postpartal exercises with resumption of normal activities as tolerated -Encourage to eat foods that are rich in proteins and Vitamin C Nursing Diagnosis Risk for uterine infection related to episiotomy Planning After 8 hours of nursing care, the client will be able to: -verbalize understanding of risk factors Nursing Interventions -Monitor vital signs Rationale -Alterations from normal may be signs of infection -Appropriate self care of the perineum in postpartum patients reduces the risk of bacterial invasion -Circulation of blood is promoted through regular movements thus it helps in the healing process -Vit.C is known to prevent infection: Protein is needed for tissue repair and regeneration Evaluation After 8 hours of nursing care, the client: -verbalized understanding of risk factors -identified interventions and demonstrate techniques to prevent risk for infection

-Proper perineal care and hygiene

-Encourage to have enough rest and sleep

-This promotes healing by reducing basal metabolic rate and allowing oxygen and nutrients to be utilized for tissue growth, healing and regeneration