Problem Nursing Background Goal and Objectives Nursing Intervention Rationale Evaluation

Diagnosis Knowledge

Pain Pain related to Oxytocin was After 4 hours of Independent: After 4 hours of nursing
uterine released to nursing intervention 1. Promote perineal -decrease discomfort intervention the patient
the patient will exercise and
S: cramping and contract the was able to experience
experience lesser comfortable sitting
“Sobrang perineal suture uterus to pain and above a position such as: lesser pain and above a
sakit kasi as manifested decrease tolerable level as - Kegel’s exercise - three or four times a day tolerable level as
nung sa by pain scale of bleeding and manifested by: with five times succession manifested by:
tiyan ko 7/10 and causes - Pain scale of reduces discomforts and - Pain scale of 4/10
saka sa grimace and contraction of at least 5/10 improves circulation in the - RR of 18bpm
tahi ko” irritability the uterus - Stable RR or area and decrease edema - No facial grimace
at least below
as causes uterine - before sitting squeeze noted
20bpm - Sitting position
verbalized cramps. - No facial buttocks together and sit - Calm and
by the Under a great grimace with that position reduces cooperative
patient deal of pressure - Slight physical discomfort Therefore the goal was
during delivery, irritability and 2. Tell patient that the - so that the patient may fix met.
O: perineum most of the time pain and discomforts her mind frame about the
• Pain responds by the is calm usually last more pain, this in return will
than 3 days
scale of development of lessen the perception of
7/10 edema and pain and her anxiety
• PR: 88 generalized 3. Instruct patient to - facilitates relaxation
• T: tenderness do breathing
37.5○C following exercises
• RR: 23 delivery. And the
• Facial episiotomy -to relieve the pain
Dependent:
grimace incisions 1. Administer
• Irritable analgesic as ordered
•dis- by physician
comfort