Assessment

Subjective:
Sobrang sakit
kasi nung sa tahi
sa tiyan ko. as
verbalized by the
patient
Objective:
- Pain scale of
7/10
- Facial grimace
- Irritable
- Discomfort
- Vital signs:
- PR: 88
- T: 37.5 C
- RR: 23

Diagnosis

Goals and
Objectives

Pain related to
uterine cramping
and perineal
suture as
maifested by pain
scale of 7/10 and
grimace and
irritability.

Long term:
After 3 days of
nursing
intervention the
patient will
experience lesser
pain and above a
tolerable level.
Short term:
After series of
nursing
interventions, the
patient will be able
to:
- Verbalize
lessening of level
of pain.
- Appear slight
irritability and
most of time is
calm.
- Appear to have
no facial grimace.

Planning
After 4 hours of
nursing
interventions, the
patient will be
relieved or
controlled.

Intervention
Independent:
1. Promote
perineal exercise
and comfortable
sitting position
such as:
- Kegels exercise
- Sitting position
2. Tell patient that
the pain and
dicomforts usually
last more than 3
days.
3. Instruct patient
to do breathing
exercises/

Dependent:
1. Administer
analgesic as
ordered by
physician.

Rationale
- Decrease
discomfort
- Three or four
times a day with
five times
succession
reduces
discomforts and
improves
circulation in the
area and decrease
edema
-Before sitting
squeeze buttocks
together and sit
with that position
reduces physical
discomfort so that
the patient may fix
her mind frame
about the pain this
in return will
lessen the
perception of pain
and her anxiety
- To relieve the
pain

Evaluation
After 4 hours of
nursing
intervention the
patient was able
to experience
lesser pain and
above tolerable
level as
manifested by:
- Pain scale of
4/10
- RR of 18bpm
- No facial
grimace noted
- Calm and
cooperative
Therefore the goal
was met.

Assessment
Subjective:
Masakit yung
tahi ko lalo na
pag
gumagalaw
ako. as
verbalized by
the patient.
Objective:
- Pain scale:
8/10
- Guarding
behavior
- Facial
grimace
- Irritable
- Skin warm to
touch
- Vital signs
taken as
follows:
BP: 110/80
PR: 80
RR: 22
T: 97.6

Diagnosis
Acute pain related
to disruption of
skin and tissue
secondary to
cesarean section.

Goals and
Objectives
Long Term:
After 3 days of
nursing
interventions, the
patient will be to
display timely
healing of skins
lesions/wounds
without
complication.
Short Term:
After series of
nursing
interventions, the
patient will be able
to:
- Verbalize
decreased
intensity of pain
from 8/10 to 3/10.
- Participate in
demonstarting
techniques to
relieve pain.
- Have ability to
manage the
situation.

Planning
After 4 hours of
nursing
interventions the
patient will be
able to manage
pain relieve and
controlled from 4
to 6 to 2-3 on the
pain rating scale.

Intervention
Independent:
1.) Established
rapport.
2.) Provide
comfort measures
such as
repositioniing or
quiet environment
3.) Monitor Vital
Signs
4.) Instruct patient
to use supportive
materials such as
binder.
5.) Perform
bedside care
6.) Encourage use
of relaxation
technique like
deep breathing
exercises.
Dependent:
Administer
analgesics or non
steroidal anti
inflammatory
drugs as
prescribed.

Rationale

1.) To have a
good nurse-client
relationship.
2.) To alleviate
pain by promoting
non pharmalogical
pain
management.
3.) To have a
baseline data and
for comparison for
future data.
4.) To reduce pain
especially when
moving.
5.) To enhance
patients self
esteem and to
provide comfor to
the patient.
6.) Relives muscle
and emotional
tension
- To relieve mild or
moderate pain.

Evaluation
After 4 hours of
nursing
interventions the
patient has able to
manage pain
relieve and
controlled from 4
to 6 to 2-3 on the
pain rating scale.
- Therefore the
goal was met as
evidenced by the
patient.