SILLIMAN UNIVERSITY
COLLEGE OF NURSING
CUES/EVIDENCES
Subjective data:
Client verbalized “ gahapon
ni sakit akung tiyan mauna
nag pakunsulta ku sa
doctor, pero nawala man
tung ni papauli ko”
Client verbalized “gaining
buntag ni sakit akuang
tiyan”
Client rated 5 from the scale
from 0 to 10, 0 meaning no
pain and 10 being the
highest pain.
Objective data:
Vital signs taken 11/20/08
 Temperature: 36.40C
 Pulse: 120 bpm;
strong and palpable
 Respiration: 20Cpm;
regular and shallow
without the use of
accessory muscle
NURSING DIAGNOSIS
Altered Comfort Pain related to
on and off uterine contractions
DUMAGUETE CITY
NURSING CARE PLAN
OBJECTIVES
At the end of our 8 hour care the
client will be able to:
 Maintain vital signs within
normal range:
T=36.5-37.5’C
P=60-100bpm
R=16-20 cycles per minute
 Rate pain as 1-2 from the
scale of 0-10, 0 being no pain
and 10 being the highest pain
 Follow prescribed
pharmacologic regimen
 Verbalize methods that
provide relief
 Demonstrate use of
relaxation skills and
diversional activities as
indicated for individual
situation
INTERVENTIONS
Independent:
 Monitor vital signs
 Perform pain assessment
each time pain occurs
 Observe non verbal cues
like how client walks or
holds body
 Encourage verbalization of
feelings about pain
 Encourage diversional
activities
 Provide quiet environment
RATIONALE EVALUATION
At the end of our 8 hour
 To obtain baseline data care:
for futuristic comparison
 Vital signs are within
 To rule out worsening of normal limit:
underlying PR:82 bpm; strong and
condition/development of palpable
complication RR:20cpm, shallow,
regular and without
use of accessory
 Observations may/ may muscle
not be congruent with T:37.50C
verbal reports indicating BP:110/70
need for further
evaluation  Rated pain as 2 from
the scale of 0-10, 0
 Verbalizations of pain being no pain and 10
serve as a cue for proper being the highest pain
nursing intervention and
these intervention will  Client was able to
reduce felt pain follow the medication
and treatment made by
doctor.
 Divertional activities
distracts the patient upon
feeling pain
 Client verbalized
 Clients who are in pain
different methods and
gets so irritated
purposes of:
 To decrease pain felt by
 Blood pressure:
100/80 mmHg
* Observe client frequently
massaging its abdomen
* Observed that client is
always stretching upon
sitting on bed
 Perform back rub for at the client
least 15 min. - Distraction technique
-Deep breathing
 Reduces pain by blocking - Back Rub
 Teach patient deep the pain impulses
breathing.
 CUES/EVIDENCES
Subjective:
 Client verbalized, “dili jud
ko comportable maglihok-
lihok kay mahadlok japon
ko sa akong samad.”
 Client verbalized, “sakit
siya king mangihi,kana
bang murag hapdos.”
 Client rated 7 from the
scale of 0 to 10, 0
meaning no pain and 10
being the highest pain.
Objective:
 Vital signs taken 11/20/08
-Temperature: 36.40C
-Pulse: 82 bpm; strong and
palpable
-Respiration: 20cpm; regular
and shallow without the use of
accessory muscle
-Blood pressure: 110/70
mmHg
NURSING DIAGNOSIS
Altered comfort: Pain related
to presence of surgical
incision in the perineum
OBJECTIVES
At the end of our 8 hour
nursing care the client will be
able to:
 Maintain vital signs within
normal range:
T=36.5-37.5’C
P=60-100bpm
R=16-20 cycles per
minute
 Rate pain 3-5 from the
scale of 0-10; 0 without
pain and 10 as the
highest pain
 Expresses feeling of
comfort and relief of pain
 Understands and carries
out appropriate
interventions for pain
relief
 Demonstrate use of
relaxation skills and
diversional activities as
INTERVENTIONS RATIONALE EVALUATION
Independent: At the end of our 8 our care:
 Assess the patient’s pain  To obtain information and
symptoms plan appropriate
interventions Client verbalized “dili na
kaayo sakit akuang kinatao
 Discuss with the patient  To decrease anxiety and day”
reasons for her discomfort increase compliance
and its expected duration
 To detect trauma to the  Patients vital signs are
 Examine episiotomy site with/in normal range:
perineal tissues or
for redness, edema, -T= 37.50C
developing complications
ecchymosis, drainage and
approximation -P=82bpm; strong and
palpable
 Inspect the perineum for  Hemorrhoidal care will help -R=20cpm; shallow, regular
hemorrhoids. Provide decrease patient
and without use of accessory
instruction on discomfort
hemorrhoidal care muscle
 Divertional activities -BP=110/70
 Encourage diversional
activities distracts the patient upon
feeling pain
 Client rated pain as 4 5
from the scale of 0-10; 0
without pain and 10 as the
Dependent: highest pain
 Client verbalized different
 Encourage the use of sitz  Sitz baths with cold water
methods and purposes of:
bath. Bath should be cool decreases edema and
to cold for the first day,
promote comfort
and warm, about three
 Patient feels indicated for individual times a day for 20 - Distraction technique
uncomfortable upon situation minutes. -Deep breathing
standing-up and
ambulation
 Administer with  Thought to inhibit
prescription Celebrex 400 prostaglandin synthesis,
mg/tab 1 OD. impeding cyclooxygenase-
2 (COX-2), to produce
aniti-inflammatory,
analgesic, and antipyretic.