N For Pain Ob 262l1p

Problem

Pain S: “Sobrang sakit kasi nung sa tiyan ko saka sa tahi ko” as verbalized by the patient O: • Pain scale of 7/10 • PR: 88 • T: 37.5○C • RR: 23 • Facial grimace • Irritable •discomfort

Nursing Diagnosis

Background Knowledge

Goal and Objectives

Nursing Intervention

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

Oxytocin was released to contract the uterus to decrease bleeding and causes contraction of the uterus causes uterine cramps. Under a great deal of pressure during delivery, perineum responds by the development of edema and generalized tenderness following delivery. And the episiotomy incisions

After 4 hours of nursing intervention the patient will experience lesser pain and above a tolerable level as manifested by: - Pain scale of at least 5/10 - Stable RR or at least below 20bpm - No facial grimace - Slight irritability and most of the time is calm

Independent: 1. Promote perineal exercise and comfortable sitting position such as: - Kegel’s exercise

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Sitting position

2. Tell patient that the pain and discomforts usually last more than 3 days 3. Instruct patient to do breathing exercises Dependent: 1. ister 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 - facilitates relaxation

-to relieve the pain

Evaluation

After 4 hours of nursing intervention the patient was able to experience lesser pain and above a 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.