Nursing Diagnosis Rank Justification

• Acute pain r/t post perineal sutures

•Activity intolerance

1

2

•Acute pain related to post perineal suture an actual problem. Pain is considered as a high priority since pain is seen in the top rank of Maslow’s hierarchy of needs under physiology. Pain can affect stimuli in the body which can lead to weakness, increase body temperature, unstable vital signs and other further complications. Pain is related to post perineal suture wherein the weakened body is more susceptible to infection. It is a subjective expression of feeling and must be immediately assessed to avoid further complication.

It is a medium priority since the problem can be seen in the Maslow’s second stage which is safe and security prior to physiologic needs. The need for safety has both physical and psychologic aspect. The person needs to feel safe, and due to activity intolerance the physical activity of the person can be altered.

Nursing Diagnosis Rank Justification

• Risk for infection 3 Risk for infection is viewed as a potential problem and is not highly threatening. This problem can be a threat if the site of wound is not cleansed well and is an open wound. And through that, an actual infection may occur. Since it is just a perceived problem, proper interventions can still be done in order to prevent it in becoming an actual problem.

Nursing Diagnosis

Analysis Planning Nursing Interventions

Rationale Evaluation

Acute pain r/t post perineal sutures

Cues:I: “hindi agad tumalab yung anesthesia nung ininject sa akin kaya medyo masakit parin ang tahi” as verbalized by the client

O:y-facial grimace-pallor-presence of perineal suture-pupillary dilationM:Pain scale:6

Pain is an unpleasant sensation localized to a part of the body. It is often described in terms of a penetrating or tissue-destructive process (e.g., stabbing, burning, twisting, tearing, squeezing) and/or of a bodily or emotional reaction (e.g., terrifying,

Goal:After 1 hr of nursing intervention, the client’s pain will be decrease from pain scale of 6 to 3

Objective:After 30 mins of nursing intervention the client will be able to:

1. Define the meaning of pain

Supplemental:-Monitor vital signs

-Monitor skin color

-Assess for drug’s side-effects

-for baseline and this is usually altered in acute pain(p.501 Nanda 11th Edition)

-for baseline and this is usually altered in acute pain(p.501 Nanda 11th Edition)

-to ensure safe administration and adequate pain relief(p.373 Joyce M. Black, Medical-Surgical Nursing Vol.1)

After 1 hr of nursing intervention, the client’s pain was decreased from pain scale of 6 to . With no presence of facial grimace. Skin color varies from light to deep brown and pupil slightly constricted.M:Pain scale-3

nauseating, sickening). Furthermore, any pain of moderate or higher intensity is accompanied by anxiety and the urge to escape or terminate the feeling. These properties illustrate the duality of pain: it is both sensation and emotion. When acute, pain is characteristically associated with behavioral arousal and a stress response

2. Identify the different causative factors of pain

3. Enumerate the signs and symptoms of acute pain

4. Know the degree of pain scale

5. Know the importance of treating the pain that is caused by the perineal suture

6. Know the ways of treating the pain caused by the perineal suture

-Check for the condition of the surgical site

-Promote comfort measures such as therapeutic touch

-Give episiotomy care specifically sitz bath

-to rule out worsening of underlying condition of complications(p.500 Nanda 11th Edition)

-to promote non-pharmacological pain mng’t(p.501 Nanda 11th Edition)

-Sitz bath helps to decrease inflammation and relieve tension in the area.(p.637 Pillitteri, Maternal and Child)

Effectiveness:The interventions are effective. The mother pain decreased.

Efficiency:Theinterventions done efficie ntly.

Adequacy:The interventions was adequate to decrease the pain.

consisting of increased blood pressure, heart rate, pupil diameter, and plasma cortisol levels. In addition, local muscle contraction (e.g., limb flexion, abdominal wall rigidity) is often present.

7. Demonstrate ways on how to treat the pain caused by perineal suture

8. Keep the area of perineal suture clean and free from pain

-Administer cold an hot therapy

-applying an ice of cold pack to the perineum during the first 24 hours reduces perineal edema and the possibilty of hematoma formation, thereby reducing pain and promoting healing and comfort.(p.637 Pillitteri, Maternal and Child)

Appropriateness:The interventions are appropriate with the client’s condition and needs.

Acceptability:The interventions made are acceptable because it is simple and easy to understand and perform.

Developmental:-Encourage client to verbalize feeling of pain

-Discuss the actions, side-effects, dosages, and frequency of administration of prescribed analgesics

-Discuss to the client the healing time of the suture.

-to assist client in alleviation of pain(p.501 Nanda 11th Edition)

-discussing to the client the side-effects of the drug before administration is necessary to ensure(p.501 Nanda 11th Edition)

-discussing to the client the time frame of healing will improve clients knowledge.(p.637 Pillitteri, Maternal and Child)

-Review ways to lessen pain such as therapeutic touch

-therapeutic Intervention with someone experiencing pain may include facilitating client’s expression of feelings about the pain which imparts a sense of being cared for; with enhanced potential to obtain satisfactory pain reduction(p371 Joyce M. Black, Medical-Surgical Nursing Vol.1)

Facilitative:-Check the medical order for drug, dose, and frequency of analgesic prescribe

-Administer analgesic drug as prescribe by the physician

Supplemental:-Evaluate client’s response to analgesia

-to ensure the 5 rights: client, drug, dose, time, route(http://www.scribd.com/doc/10060583/Nursing-Care-Plan-Acute-Pain)

-to maintain “acceptable” level of pain. Helps decrease pain.(p.502 Nanda 11th Edition)

-increasing /decreasing dosage, helps on pain mng’t(p.502 Nanda 11th Edition)

MEDICATIONSEncourage the client to comply with the medications

prescribed by the physician. Emphasize the importance of taking medications as prescribed.

Explain to the client and family the right dose, route, and frequency of his home medications.

Explain to the client and to his family the use of his medications to help in their understanding of its importance.

ENVIRONMENTS• Provide a clean and calm environment with

adequate ventilation for the child.

• Advise the family to provide a stress free environment that is conducive for rest and relaxation of the mother.

• Suggest the family to provide accessibility of the mother and baby’s necessities considering their condition.

TREATMENTExplain to the client and client’s family about the

essence of compliance to treatment regimen such as continuous prescribed medications for the mother and strict adherence to the child’s follow-up check-up for regular monitoring of condition.

Explain to the mother the importance immunization needed by the baby.

HEALTH TEACHINGS• Remind the relatives to give assistance to

the client for continuity of self care needs.

• Teach the client about the importance of breast feeding.

• Promote to the couple the safe family planning.

• Teach and inform the client about the different immunizations needed by the baby.

OUT- PATIENTAdvise the mother regarding follow-up care in the

lying-in as much as possible.

Tell the client to immediately report to health workers if there’s any unusual symptoms felt, including the baby.

SPIRITUAL/SOCIAL• Encourage the family to pray everyday and

be thankful for the new blessing given by God.

• Encourage the relatives to frequently communicate positively with the client and ask the client to verbalize her feelings without hesitation.

• Encourage to create a mother-baby bond.

DIET• Advise the mother to eat nutritious foods

such as vegetables, fruits, and fish every meal to the client.

• Advise client to increase fluid intake as much as 8 glasses of water everyday.

• Promote breastfeeding to the baby.