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akong tahi
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION At the end of our care all objectives were partially met as evidenced by:
Altered comfort: acute Within our 2 days of pain related to surgical nursing care the patient incision secondary to will be able to: episiotomy wound. y Vital signs in normal range T= 36.5 C-37.5 C P=60-100bpm R=15-20cpm BP=110-140/6090 mmHg y Monitor patients vital signs. y To obtain baseline data
Objectives: y VITAL SIGNS T: 36.5 C R: 17 cpm P: 75 bpm BP: 120/85 mmHg y Client rate the pain 4 (1 lowest10 highest)
Vitals signs: T=37.1 C, warm to touch. P=73 bpm, regular R=23 cpm, no use of accessory muscles. The patient was able to observed evidence of pain.
y y LABORATORY RESULT URINALYSIS Color: yellow Transparency: slight hazy y Patient report of less pain. y
Accepts clients percerption of pain. Acknowledge the pain experience and convey acceptance of clients response of pain. Assess patient s general health condition.
The patient reports less pain especially when she takes her medication.
Sp. Gravity: 1.030 Glucose: negative Protein: negative pH: 6.5 y y y y Profused sweating Limited movement Restless
Verbalize of relief.
feeling
Promotes feeling of rested, comfort and also avoid fatigue. To cleanse the body and feeling of relief also to reduce the risk of infection. Each client has a right to expect maximum pain relief. Medications ordered PRN basis should be offered to the client at the interval when the next dose is available..
The patient verbalized the feeling of comfort. The patient able to verbalize feeling of relief from cleansing bedbath. The client was able to take her prescribed medications.
y Facial Grimacing