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Assesment Nursing Diagnosis Scientific Explanation Goal Nursing Interventio N Rationale Evaluation

1. The nursing diagnosis was pain related to a second degree perineal laceration from a normal spontaneous delivery. 2. Short term goals were to reduce the client's pain in the perineal area through pain medication and teaching proper perineal care. 3. Long term goals were for the client to no longer experience pain in the laceration after 1 week of postpartum period.

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Dickson,Emilia Jade
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959 views2 pages

Assesment Nursing Diagnosis Scientific Explanation Goal Nursing Interventio N Rationale Evaluation

1. The nursing diagnosis was pain related to a second degree perineal laceration from a normal spontaneous delivery. 2. Short term goals were to reduce the client's pain in the perineal area through pain medication and teaching proper perineal care. 3. Long term goals were for the client to no longer experience pain in the laceration after 1 week of postpartum period.

Uploaded by

Dickson,Emilia Jade
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ESMENT NURSING SCIENTIFIC GOAL NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTIO


N

ective: Pain related A second degree Short term: Independent:


sakit po ng to 2nd degree laceration is a 1. Instruct To promote
t ko sa perineal common tear that can -After 2 patient to do sitz healing and MET- after 2
neal area laceration happen while having hours, the bath promote hours of
g kapag secondary to a baby. When the patient will be comfort due nursing
hi po ako” as normal baby is big and the able to to its muscle intervention,
alized by the spontaneous perineum is being experience relaxant the client
t. delivery over stretched. These reduce pain 2. The nurse will effect and reported that
tears go through the in perineal demonstrate the promote the pain
skin into the muscles area because use of peri- good blood medication
ctive: underneath the of the bottle, witch flow supply was effective
vagina. Second effectiveness hazel pads, and that will in reducing
Signs: degree of pain lidocaine spray promote her pain and
lacerations sometime medication for pericare faster as evidenced
6.7 s need sutures. The following healing by absence of
87 bpm sutures will help to -to do health urination and facial grimace
19 bpm hold the edges of teaching defecation. and a pain
20/80 the tear together to about Clients who scale of 3/10
Hg allow it to heal. perineal care understand and the client
: 6/10 3.Teach proper self-care was able to
perineal care methods demonstrate
ial grimace from front to experience the steps in
back decreased of perineal care
anxiety and routine
4.Nurse will an increase .
Long term: request a teach- of sense of
After a week back from the control. MET- After a
of postpartum client the next week of
period, the time she uses postpartum
mother will the restroom. Front to back period, the
no longer perineal care mother no
experience will lessen longer
pain in her the  risk of experience
laceration Dependent: introducing pain in her
germs from laceration
1. The nurse will the anal area
administer into the
Mefenamic for urethra, a
pain and primary
Amoxicillin to source of
prevent infection urinary tract
as prescribed by infeaction.
Doctor J

Ensuring
that the
client
understands
her role in
the pain
management
regimen that
can result in
better pain
control.
Mefenamic
targets to
relieve and
reduce pain
and
Amoxicillin to
prevent
infection

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