CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjectives: Altered comfort: acute Within our 2 days of At the end of our care
Client verbalized pain related to surgical nursing care the patient all objectives were
that incision secondary to will be able to: partially met as
 “sakit ang akong episiotomy wound. evidenced by:
tahi usahay”
 “ mag ngut-ngot  Vital signs in  Monitor patients  To obtain baseline  Vitals signs:
pud usahay ang normal range vital signs. data T=37.1 ⁰C, warm
akong tahi” T= 36.5⁰C-37.5⁰C to touch.
P=60-100bpm P=73 bpm,
R=15-20cpm regular
BP=110-140/60- R=23 cpm, no use
90 mmHg of accessory
Objectives: muscles.
 VITAL SIGNS
T: 36.5 ⁰C  Observed  Accepts clients  Pain is subjective  The patient was
R: 17 cpm evidenced of pain. percerption of experience and able to observed
P: 75 bpm pain. cannot be felt by evidence of pain.
BP: 120/85 mmHg Acknowledge the others.
pain experience
 Client rate the and convey
pain 4 (1 lowest- acceptance of
10 highest) clients response of
 pain.

 LABORATORY  Patient report of  Assess patient’s  To determine  The patient

RESULT less pain. general health deviations from reports less pain
URINALYSIS condition. normal and obtain especially when
Color: yellow subjective cues. she takes her
Transparency: medication.
slight hazy
 Sp. Gravity: 1.030  Verbalized feeling  Provide adequate  Promotes feeling  The patient
Glucose: negative of comfort. rest. of rested, comfort verbalized the
Protein: negative and also avoid feeling of comfort.
pH: 6.5 fatigue.
 Verbalize feeling  Perform cleansing  To cleanse the  The patient able
 Profused sweating of relief. bedbath to the body and feeling to verbalize
patient. of relief also to feeling of relief
 Limited movement reduce the risk of from cleansing
infection. bedbath.
 Restless
 On the given,  Provide optimal  Each client has a  The client was
 Facial Grimacing administer pain pain relief with right to expect able to take her
reliever to the doctor’s maximum pain prescribed
client. prescribed relief. Medications medications.
analgesics ordered PRN
basis should
be offered to
the client at
the interval when
the next dose is
available..