Jenny Juniora Ajoc
BSN 211 - Group 1A
Patient’s Name: Jeremiah Ramos Age: 19 years old
I. PROBLEM IDENTIFICATION AND PRIORITIZATION
Nursing Diagnosis With Cues
Acute pain RT impaired skin integrity secondary to
episiotomy incision
Subjective cues: Throughout the interview, patient
repeatedly says “Sobrang sakit po ng tahi ko.” She
insists on relief for the pain by asking “meron po ba
akong pwedeng inumin na gamot para sa sakit?”. In
addition to acute pain due to episiotomy incision,
patient also verbalized that “medyo masakit din po
‘yung nakakabit na dextrose ko”
Objective cues: Pain scale rating of 10/10 (1 lowest,
10 highest) described as sharp or stabbing located on
sutures and right lumbar area. Upon general survey,
Fatigue, slow speech, irritability, distress, and partial
compliance to interview questions can be noticed.
Patient grimaces upon movement and immediately
clutches right lumbar area.
October 17, 2019
Rank Justification According to Maslow’s
1 Pain can also be considered as the fifth vital sign as it can be an
early predictor of impending disability (Kelley & Weber, 2018).
Classifying pain also as a vital sign makes it detrimental to human
life if not addressed. In this case, pain was caused by a physiologic
condition of the patient namely the episiotomy incision or suture
that she had. According to Maslow’s hierarchy of needs, it is
important to address physiologic needs first before the others.
Since pain is an immediate physiologic need, it is important to
address it especially if on the pain scale it scores a high number
such as 10. A 10 on a pain scale means that it may be The patient
can become physically and psychologically impaired by this pain
that will negatively affect all other treatments or interventions
given, not to mention that it will cause her great discomfort.
Sources:
Kelley, J. & Weber, J. (2018). ​Health Assessment in Nursing.
Philippines. Wolters Kluwer Health. p. 121
Imbalanced nutrition: less than body requirements RT 2 Since this is also a physiologic need, this should be addressed next
lack of knowledge about postpartal needs in Maslow’s hierarchy of needs. And since this condition does not
affect the patient’s immediate physiological or emotional status, it
Subjective cues: Patient verbalizes that she is hungry goes second to the previous nursing diagnosis. Postpartum patients
and has not yet eaten a proper meal since admission at need an adequate amount of nutrition and hydration in order to
2PM October 9, 2019. She also stated “malakas ako properly recover from childbirth.
uminom ng tubig noong pagkatapos manganak pero
nawawalan na ako ng gana katagalan”.
Objective cues: Within 16 hours (since delivery at
8PM to time of interview at 12:00PM): No bowel
movement or urination. Fluid intake of 500mL. 1
pack of crackers (skyflakes) for snacks. Skin exhibits
pallor, most prominent on lips.

Risk for falls RT impaired mobility 3 According to Maslow’s hierarchy of needs, all physiologic aspects
of a person’s health needs have to be addressed first. Risk for falls
Subjective cues: Patient verbalizes that she is too is categorized under safety and security which goes next in the
weak and in pain to move properly. hierarchy.
Objective cues: Decreased mobility of the patient due
to pain and fatigue secondary to postpartum
condition. Unelevated bed railings.

Readiness for enhanced parenting AEB verbalization
of willingness towards enhanced motherhood
Subjective cues: Upon interview, patient verbalized
that her feelings towards motherhood is a bit nervous,
but excited. She stated that she is looking forward to
the fulfillment that it holds ahead.
4 Becoming a parent can lead to a sense of self-fulfillment. Before
these kind of needs can be addressed, the person first has to
complete his / her basic needs and psychological needs.
Furthermore, Actual and risk diagnoses need to be prioritized
before a wellness diagnosis.
II. NURSING CARE PLANS

A. First Priority
Cues Diagnosis Analysis Goals and Intervention Rationale Evaluation
Objective

Objective cues: Acute pain Pain can also SHORT INDEPENDENT 1. After 30 mins
related to be considered TERM INTERVENTION - 1 hour of
- Pain scale rating impaired as the fifth administering
of 10/10 (1 lowest, skin vital sign as it - Relieved to at - Assess patient; - to verify patient’s analgesic, along
10 highest) integrity can be an early least 5/10 in note current pain and to with cold pack,
described as sharp secondary predictor of pain scale by condition and determine patient was able
or stabbing located to impending end of shift other factors that appropriate to describe the
along sutures and episiotomy disability might affect ability interventions pain as tolerable
right lumbar area. incision (Kelley & - Verbalize to report pain and less than or
Weber, 2018). feeling of parameters equal to 5/10
Vital signs​ (as of It can be comfort, lessen pain scale
11:55AM 10/10/19) objectively distress and - Administer cold - applying cold _​x​_ met
Temp: 36.6​°C measured by irritability by therapy packs during the __ unmet
BP: 110/70 using pain end of shift first 24 hours __ partially met
CR: 89 bpm scales. The reduces perineal
RR: 18 cpm patient can - Increased edema, reduces 2. Able to
become knowledge of pain, and promotes exhibit use of
- Fatigue, slow physically and pain healing and comfort. relaxational
speech, irritability, psychologicall management acivity: Kegel
distress, and partial y impaired by methods using - Demonstrate use - To lessen focus on exercise
compliance to this pain that relaxation of relaxation skills pain. Back rubs are __ met
interview. will negatively skills and and diversional effective for _​x​_ unmet
affect all other diversional activities, namely relieving an aching __ partially met
- Patient grimaces treatments or activities back rubs and back or shoulders,
upon movement interventions Kegel exercises while kegel 3. Patient
and immediately given. LONG TERM exercises improves reports that she
clutches right circulation to area is soothed or
lumbar area. Sources: - Pain will be and decrease edema. less irritable
Kelley, J. & alleviated than from the
Subjective cues: Weber, J. entirely by the - Accepts client’s - According to beginning of the
(2018). ​Health time perception of pain. Kelley & Weber shift
- Throughout the Assessment in Episiotomy Convey (2018), the most _​x​_ met
interview, patient Nursing. wound should acceptance and important definition __ unmet
repeatedly says Philippines. heal at Verbalize sense of of pain is that “pain __ partially met
“Sobrang sakit po Wolters approximately control of response is whatever the
ng tahi ko.” Kluwer Health. 2 weeks to acute situation person says it is”.
p. 121 and positive Comforting the
- Patient insists on outlook for the patient will provide
relief for the pain future emotional support
by asking “meron
po ba akong DEPENDENT
pwedeng inumin na INTERVENTION
gamot para sa
sakit?” - Provide optimal - to provide
pain relief with immediate relief for
- In addition to doctor’s patient’s pain
acute pain due to prescribed
episiotomy analgesics Sources:
incision, patient Kelley, J. & Weber,
also verbalized that J. (2018). ​Health
“medyo masakit Assessment in
din po ‘yung Nursing.
nakakabit na Philippines. Wolters
dextrose ko” Kluwer Health. p.
413
B. Second Priority
Cues Diagnosis Analysis Goals and Intervention Rationale Evaluation
Objective

Objective cues: Imbalanced Digestion and SHORT TERM INDEPENDENT 1. after health
Within 16 hours nutrition: absorption begin INTERVENTION teaching, patient
(since delivery at less than to be active - For the patient was able to
8PM to time of body again soon after to understand - Health teaching - Increasing identify the range
interview at requiremen birth except if postpartum about proper diet patient’s of values for fluid
12:00PM): ts related to delivery was a and nutrition for knowledge will intake, daily
lack of cesarean. The - Familiarize postpartum empower them calorie intake (for
- No bowel knowledge mother will mothers, and equip them breastfeeding
movement or about almost LONG TERM importance or with the necessary mothers), and type
urination. postpartal immediately feel purpose of it, and tools for wellness of food she should
needs hungry and risks of not and achieve self - eat within her stay
- Fluid intake of thirsty and adhering. efficacy. __ met
500mL. according to __ unmet
Pilliteri (2018), - promote - to replace fluid _​x​_ partially met:
- only ate 1 pack she can already adequate fluid lost during labor patient was only
of crackers eat without intake and childbirth. able to identify
(skyflakes) for difficulty during what type of food
snacks. this time. COLLABORATI she should eat
Furthermore, VE within her stay
- Skin exhibits postpartal menu INTERVENTION
pallor, most planning should 2. By the end of
prominent on include a diet of - refer patient to a - properly shift, patient is
lips. 2,200 - 2,300 dietician to planning diet and able to drink a
calories daily. construct a nutrition with a further 500mL or
Subjective cues: Since postpartum diet professional more of water /
postpartum plan increases able to finish the
- Patient patients are effectivity of rest of the water in
verbalizes that mostly regimen and also her 1000mL
she is hungry and breastfeeding, helps address container.
has not yet eaten they need an additional __ met
a proper meal additional 500 concerns _​x​_ unmet
since admission calories and regarding diet as __ partially met
at 2PM October additional 500ml well (if any).
9, 2019. of fluid to 3. Patient is able
supplement the to eat at least 1
- Patient does not process. Letting full meal
eat that much them know the consisting of
due to notion that proper diet and produce or soluble
bowel movement nutrition are fiber foods by end
might hurt if she important factors of shift
eats too much to consider when _​x​_ met
food. caring for these __ unmet
patients. __ partially met
- patient
verbalizes desire 4. Within a week,
to know more Sources: able to create a
about what food Silbert-Flagg, J. meal plan to
she is allowed A., & Pillitteri, adhere to.
and not allowed A. (2018). __ met
to eat during Maternal & _​x​_ unmet
postpartum Child Health __ partially met
period Nursing: Care of
the Childbearing
& Childrearing
Family (8th ed.)​ .
Philadelphia.
Wolters Kluwer.
Vol. 1., pp. 406.