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5˚C-40. As ordered. Encourage the use of sitz bath. on how to use sprays. Apply ice to the episiotomy site. should take sitz bath 3-4 times per day. DIAGNOSIS Acute pain related to post partum physiologic changes as evidenced by a self. as verbalized. 2. To increase vasoconstrictio n and reduce edema and discomfort. Baths should be cold for the first day and warm (37. the pt. 2. Objective: Pain scale of 6 Presence of facial grimace Restlessness 3. The pt.6˚C) thereafter. teach the pt. moist heat increases circulation to the perineum. PLANNING After two hrs. INTERVENTION INDEPENDENT: 1. After 24 hrs. with each lasting about 20 min. . of nursing intervention. creams and ointments for the perineal area. RATIONALE EVALUATION Goal met as evidenced by pt. after 2 hrs. Sitz baths with cold water decrease edema and promote comfort. 1. reduces edema.focus. will be able to express comfort and relief from pain. of nursing intervention.NORMAL SPONTANEOUS VAGINAL DELIVERY ASSESSMENT Subjective: “masakit ang akon tinahian”. verbalization of comfort and relief of pain with a pain scale of to 6 to 3.

4. She shouldn’t use the same position every time. 3. providing depressant effect on 5. to tighten the buttocks before sitting and to sit on flat. DEPENDENT: peripheral nerves. Tightening gluteal muscles before sitting . And to position the neonate properly during feedings.promotes healing and enhances 4. Encourage to wear a supportive bra when breast feeding. oxygenation and nutrition of tissues. thereby reducing the response to sensory stimulation. She should avoid foam donuts or soft pillows. Encourage the pt. These products penetrate sensory nerve endings. padded surface.

they may decrease venous blood flow to the affected area. thereby increasing discomfort. administer pain medications o naproxen sodium(Skelan) o meperidine(Demerol) reduces stress and direct pressure on the perineum. This will help prevent sore nipples. 5. Because donuts separate the buttocks. To increase comfort. .6. As ordered.

as verbalized. Of nursing intervention. unless contraindicate d. Objective: Limited range of motion DIAGNOSIS mobility related to musculoskeletal impairment as evidenced by a functional level of 2(requires help from another PLANNING After 8 hrs. Perform ROM exercises to joints. will be able to achieve highest level of mobility and express absence of INTERVENTION INDEPENDENT: 1. Progress RATIONALE INDEPENDENT: 1. This prevents joint contractures and muscular atrophy. EVALUATION Goal met as evidence by pt.CEREBROVASCULAR ACCIDENT ASSESSMENT poy ang akon tu-o nga kamot”. can perform full range of motion within 8 hrs.Impaired physical . of nursing intervention. at least once every shift. the pt. Subjective: “mapoy.

Turn and position pt. from passive to active. 3. . 2. 4.’s head. Place joints in functional position. every 2 hrs. These measures maintain patient’s joints in functional position and prevent musculoskelet al deformities. use big-top sneakers and put a small pillow under pt.Slow movements Shuffling gait Postural instability when performing self-care activities Difficulty turning person for assistance and supervision). hemiperesis. as tolerated. use two chanter roll along the thigh. Encourage independence 2. This prevent skin breakdown by relieving pressure. abduct the thighs. 3.

5. feeding and dressing. 6. to use her unaffected arm to move her affected arm and perform selfcare activities as combing hair. Patients with history of neuromuscula r disorder may . 6. to use a trapeze and side rails. Monitor and 4.mobility by helping pt. This increase muscle tone and patient’s self-esteem. Place items within reach of the unaffected arm. 5. To promote patient’s independence.

7.for discharge. chair mobility to ambulation). 8. be moiré prone to develop complications. 8. Encourage adequate intake of fluids or nutritious foods. 9. To help prepare pt. and prevent complications of mobility.record daily any evidences of immobility complications. . To maintain muscle tone 7. Promotes well-being and maximizes energy production. Provide progressive mobilization to the limits of patient’s condition (bed mobility.

Instruct pt. transfers. to a physical therapist for development of mobility regimen.9. 10 to help rehabilitate musculoskeletal defects. and family members in ROM exercise. COLLABORATIVE: 10. Refer pt. skin infection and mobility regimen. .


Increased specific gravity indicates lack of fluids to dilute urine. will be able to exhibit normal elimination patterns within a shift. Check urine specific gravity every voiding. 3. increased output and decrease Goal met as evidenced by pt. INDEPENDENT: 1. To replace fluid loss with causing further GI inhibition. 2. (5-15ml) of clear fluids frequently. Poor skin turgor and dry lips noted Deficient fluid volume related to active fluid volume loss as evidence by light brown watery stool not less than 100cc.Subjective: “gina LBM ako”. verbalized. Intervention. INDEPENDENT: 1. After diarrhea and vomiting have decreased. Monitor IV fluid infusion intake indicate fluid deficit. . To obtain fluid status. The pt. Record I&O every shift. exhibit formed stool after nsg. 4. Objective: Presence of gurgling sound in the abd. 2. offer small amts.

can lead to fluid imbalance more rapidly. To protect the site and allow free movement of the extremity. 5. . 4. An infusion rate that’s too fast/too slow 5.every hr. Secure IV site by wrapping it in a soft bandage.