ARNADO, ROSEJEAN L.

BSN_2

IMPRESSION: PREGNANCY UTERINE FULL TERM 39 WEEKS 6/7, DELIVERED VIA NORMAL SPONTANEOUS DELIVERY .
Nursing Assessment Diagnosis Planning Intervention Rationale Evaluation
Problem

Uterine Subjective: Altered comfort: After 3 hours of Establish rapport and determine To clarify After 3 hours of nursing
Client verbalized Bearable pain related to nursing the client’s level of comfort intervention needs intervention, the patient
Hardening
that “sumasakit po Surgical Incision interventions, the and priorities was able to describe
sa part na may secondary to the client will be able Check and monitor vital signs satisfactory pain control at
Moderate to Episiotomy Wound as to: a level of 3 on a 0-10
tahi” To note certain
mild vaginal evidenced by changes that will rating scale.
bleeding Patient Rating Pain Assess the episiotomy wound
Verbalize feelings of occur
Complains of pain 5/10 for abnormal discharge and
increased self- She also displayed
with a rating of 5 signs of infection.
esteem and ability to To avoid and identify improved well-being
points on a scale of
manage the situation possible signs of through baseline levels in
1 to 10 Cleanse the perineal area with
infections normal parameters and
lukewarm water and Povidone relaxed muscle tone or
Objective: Verbalize increased Iodine then pat with a dry towel body posture.
comfort To provide knowledge
Right mediolateral
episiotomy site. on how to apply and
Assist the client in changing She also uses
remove pads that can
the perineal pad pharmacological pain
help to
Vital signs taken maintain the skin relief strategies
as follows: Monitor the episiotomy site integrity continuously as ordered
T: 36.7 using the REEDDA (Redness, by the physician.
PR: 96 Edema, Ecchymosis,
RR: 20 To detect signs or
Discharge, Drainage, The client showed signs of
symptoms of possible
Approximation) skin infection progressive healing as
demonstrated by a clean,
DEPENDENT: dry, and intact episiotomy
To promote site.
Provide optimal pain relief with nonpharmacologic pain
a doctor’s order/prescription. management