GENERAL SANTOS DOCTORS' MEDICAL SCHOOL FOUNDATION INC.

NCM: 107-n_ RLE EXPOSURE

Area: _______OB WARD____________ Inclusive Dates: __AUGUST 31, 2020___

Patient: __DINA ROMERO___ Attending Physician: ________ Students Name: ALMERA ROSE NARCE, SN
Age and Sex: _26 YEARS OLD; FEMALE Diagnosis: _________________________ Year and Section: ___BSN-2A___
Chief Complaint: Pain in the episiotomy site. Group: ____3A________
NURSING CARE PLAN
DIAGNOSIS and
ASSESSMENT INFERENCE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
Subjective Cues: Ng Dx: Long term: INDEPENDENT: 1. To promote a trusting  After 8 hours of
Acute pain related relationship with the nursing intervention,
- “medyo masakit to episiotomy as To create or maintain 1. Establish rapport to the patient. goals are met
a therapeutic because:
ang aking puerta.” evident by pain client. 2. To provide baseline
as verbalized. scale of 6. environment. 2. Monitor the vital signs data
 Maintain vital
- Rated pain as 6 3. Assess the episiotomy 3. The amount of signs within
out of 10 Short term Goal: wound for abnormal discharge and the normal range:
discharge signs of presence of infection T:37 C
Objective Cues: Within 8 hours of infection. will help to determine PR:90cpm
VS: Inference/ nursing interventions, 4. Record and time the the appropriate RR:20bpm
T =36.6-degree Celsius Background patient will be able to: frequency, intensity, treatment needed by BP:100/80
P= 78bpm, Knowledge: - Report a interval, and duration of the patient.
R=16cpm, decrease of pain pain related to 4. To obtain baseline
BP= 115/75 mmHG Although relatively from 6 to 3. episiotomy. data regarding the  Verbalized pain
- episiotomy done small in size, - Use of pain-relief 5. Administer amoxicillin frequency, intensity, within tolerable
strategies proper limits
mediolaterally episiotomy sutures 500mg 1 capsule every interval, and duration
- uterus is firm can cause breathing and 8 hours, mefenamic of pain.  Rated pain from
midline considerable relaxation acid 500mg 1 capsule 5. Medications as 6 to 3
- with moderate discomfort, because techniques. every 6 hours PRN for prescribed by  Able to exhibit
amount of lochia the perineum is an pain physician alleviate strategies
extremely   6. Encourage verbalization pain and may help in proper
sensitive area and   of feelings about pain providing comfort to breathing and
  relaxation
the muscles of the such as concern about the patient.
  techniques.
perineum tolerating the pain 6. To evaluate coping
 
are involved in so   7. Provide for a abilities and to identify  
many activities such   therapeutic environment the areas of additional
as sitting,   that is quiet, adequately concern.
walking, stooping,   ventilated, dimly lit, and 7. Non-distracting
squatting, bending,   free of distractions. environment provides
urinating,   optimal opportunity for
 
and defecating. rest and relaxation in
 
Because the   managing the pain.  
perineal area heals    
rapidly, you    
can assure a    
woman that  
discomfort is normal  
 
and does not  
 
usually last longer    
than 5 or 6 days.    
Most primary care    
providers prescribe  
a soothing  
anesthetic cream or
spray to be applied
to the
suture line to reduce
discomfort. If a
woman is worried,
she will experience
additional
discomfort when her
episiotomy sutures
are removed,
you can assure her
these sutures will
dissolve within
10 days and thus do
not need to be
removed. (Pillitteri
8th ed, 2018)