KEY ISSUES DESIRED OUTCOMES INTERVENTIONS:

Acute pain due to episiotomy r/t labor with pain score of After 45 mins of student nurse-client interaction; the  Assess pain reports, noting location, intensity (0–10
6/10 as manifested by knowing pain when walking or patient will be able to: scale), frequency, and time of onset. Note nonverbal
standing suddenly. cues like restlessness, tachycardia, grimacing
 Patient describes satisfactory pain control at a level  Encourage verbalization of feelings.
 Provided diversional activities: provide reading
less than 3 to 4 on a rating scale of 0 to 10. materials.
 Patient displays improved well-being such as baseline  Perform palliative measures: repositioning, cold
compress and massaging
levels for pulse, BP, respirations, and relaxed muscle  Encouraged adequate periods of rest and sleep
tone or body posture.
 Patient uses pharmacological and
nonpharmacological pain-relief strategies.
 Patient displays improvement in mood, coping.

Effective breastfeeding r/t maternal confidence.
Disturbed sleep pattern due to Insomnia as manifested by After 45 mins of student nurse-client interaction; the  Educate patient about her sleep requirement
client claiming she feels tired the next day and usage of patient will be able to:
phone to aid in sleep.
After 45 mins of student nurse-client interaction; the  Assess mother’s knowledge and previous experience
patient will be able to: with breastfeeding.
 Observe mother’s return demonstration.
 Verbalize understanding of breastfeeding techniques.
 Keep infant with mother
 Promote effective breastfeeding behaviors.
 Encourage mother to drink at least 2000 ml of fluid
 Demonstrate effective breastfeeding techniques
per day.
 Promote wellness
 Provide any needed information.
 Provide follow-up check-up
 Help patient understand main cause of sleeping
 Identify causes of sleep problem difficulties
 Evaluate physical or psychological circumstances  Instruct patient to follow a consistent daily schedule
that hinders sleep for rest and sleep
 Be able to obtain optimal rest as evidenced by well-  Introduce relaxing activities such as warm bath, calm
rested appearance, verbalized that she does not feel music, reading a book, and relaxation exercise before
tired but is feeling well-rested, and improvement of bedtime
 sleep pattern.  Suggest an environment conducive to rest or sleep
 Instruct patient to not think about distracting
thoughts at bedtime

Risk for falls as manifested by absence of bathroom After 45 mins of student nurse-client interaction; the  Explain consequences of the determined risk factors
handrails and non-slip proof material. patient will be able to:  Improve home supports such as handrails, non-slip proof
materials, etc.
 Not sustain falls and free of any injury  Recommend needed interventions and safety devices that
 Modify environment as indicated to enhance safety would reduce risk
 Demonstrate selective preventive measures.