ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Acute pain secondary Within 4 hours Independent: Independent:

“sakit akong tahi to episiotomy related of nursing 1. Monitor vital 1. Vital signs are altered GOAL MET
maam” as to tissue damage interventions, signs during acute pain.
verbalized by the the patient will 2. Tell patient 2. So that the patient After 4 hours of
patient. experience that the pain may fix her mind frame nursing
Pain scale: 8/10 lesser pain and and about the pain, this in interventions, the
above a discomforts return will lessen the patient was able to
Objective: SCIENTIFIC BASIS: tolerable level usually last perception of pain and experience lesser
*facial grimace as manifested more than 3 her anxiety. pain and above a
seen Under a great deal of by: days. 3. To facilitate relaxation. tolerable level as
*irritable pressure during -pain scale of 3. Instruct 4. To assist in alleviation manifested by:
*discomfort delivery, perineum at least 5/10 patient to do of pain. -pain scale of 5/10
*dry lips response by the -no facial deep Dependent: -no facial grimace
development of grimace breathing 1. To relieve the pain noted
V/S as follows: edema and -non-irritable exercise. Collaborative: -non-irritable, calm
T: 36.5 C generalized and most of the 4. Encourage 1. To refer any and cooperative.
P: 76 bpm tenderness following time is calm rest and unusualities to the
RR: 20 bpm delivery and the and sleep physician.
BP:90/70 episiotomy incision. cooperative. Dependent:
1. Administer
Medication: Reference: analgesic as
Mefenamic acid Medical-Surgical ordered by
500 mg Nursing, 7th edition by physician.
Black, Joyce M. and Collaborative:
Jane Hokanson 1. Monitor
Hawks; p.440 laboratory
results.

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Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Deficient fluid Within the shift, Independent:
Nalipong ko volume related to patient will be able 1. Assess and 1.The amount of blood loss Goal partially
maam” as excessive blood to 1.Maintain a BP record the type, and the presence of blood met
verbalized by loss of atleast 100/60 amount, and site clots will help to determine
the patient mmHg of the bleeding. the appropriate replacement At the end of the
Count and weigh need of the patient. shift, the patient

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Objective: 2.Patient will perineal pads had increased
*body malaise SCIENTIFIC maintain a pulse and if possible BP of 100/60,
*weakness BASIS: rate between 70- save blood clots she had a
*dry Bleeding is due to 90 bpm to evaluated by balance intake
skin/mucous depletion of 3. pt. will have a the physician. and output
membrane intravascular balanced 24-hour 2. Monitor vital 2.Increased heart rate, low within 24 hrs.,
*pallor volume through intake and output signs, check for blood pressure, cyanosis, and still has a
V/S as follows: blood loss to the 4.Pt. will have a the capillary refill delayed capillary refill lochia flow of
T: 36.5 C point of being lochia flow of less and observe nail indicates hypovolemia and one saturated
P: 110 bpm unable to match the than one saturated beds and impending shock. perineal pad per
RR: 20 bpm tissue demand for perineal pad per mucous hour.
BP:90/70mmH oxygen.The body hour. membranes.
g compensates for 3. Measure 24-hour
volume loss by intake and 3.This will help in
increasing heart output. Observe determining the fluid loss. A
rate and for signs of urine output of 50-50mL/hr or
contractility. voiding difficulty. more indicates an adequate
4. Use caution circulating volume. Voiding
when performing difficulty may happen with
Reference: vaginal and hematomas in the upper
rectal portion of the vagina causing
Brunner & examinations. pressure in the urethra.
Suddarth’s 4. May increase hemorrhage
Textbook of Medical if perineal lacerations are
– Surgical Nursing present.
11th Edition by
Smeltzer, Bare,
Hinkle, Cheever

Dependent:
1.Administer
Methergine, Pitocin as 1.It increases contractility of
ordered by physician the boggy uterus and
2. administer analgesic myometrium, closes off
as ordered by physician exposed venous sinuses,
2.administer co- and stops hemorrhage.
amoxiclav

Collaborative: 2.Antibiotic acts as

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