Assessment Diagnosis Scientific Rationale Planning Interventions Rationale Evaluation

Subjective: Altered comfort: -Episiotomy is a Short-term: -Monitor the patients vital - to obtain baseline -Reports pain is
-“Masakit yung acute pain related surgical incision of the -Within 4 hrs after the signs data relieved or
tahi ko” as to surgical perineum made to nursing intervention, the controlled
verbalized by the incision prevent tearing of the patient will experience pain -Assess the episiotomy -to obtain baseline
patient secondary to perineum and release within tolerable levels wound for abnormal data and facilitate -Reports pain
episiotomy pressure on the fetal discharge and signs of prompt treatment scale of 7 or
Objective: head during childbirth. -4 hrs after nursing infection below
-Presence of (Varghese, intervention, patient will
episiotomy Champaneria, Kapoor, report pain scale of 7/10 or -Acknowledge the patient’s - Pain is a -Demonstrate
wound et al., 2016) below pain experience and subjective use of
-Facial grimace convey acceptance of experience and relaxation
-Pain scale of - -2 hours after nursing patient’s response cannot be felt by techniques and
10/10 intervention, patient will others diversional
-Discomfort no longer demonstrate activities
-Irritable grimace upon movement -Place the patient in a -To relieve the
-Guarding comfortable side-lying pressure on the -Verbalize sense
behavior -2 hours after nursing position episiotomy site of comfort and
intervention, patient will ease
demonstrate comfort and -instruct patient to perform -To facilitate
ease. deep breathing exercises relaxation -Views the labor
and delivery
Long-term: -administer Mefenamic -To maintain process as a
-Patient will view the acid 500mg/tab 1 tab PO, acceptable level of positive
process of labor and then 250mg/tab 1 tab q6 pain experience
delivery as a positive and PO for 3 days as ordered
joyful experience