ACTUAL NCP

Cues Nursing Diagnosis Planning Nursing Rationale Evaluation

Interventions
Subjective: Acute vaginal pain After 8 hours of -Provide rapport -To gain trust and After 8 hours of
“sumasakit yung related to right nursing care, the with the patient full cooperation nursing care, the
tahi paminsan medio lateral client will be able during the pain client:
minsan.” as episiotomy as to: alleviation periods
verbalized by the evidenced by facial - expressed
patient. grimace, pain scale -express alleviation -Monitor vital signs -Vital signs altered alleviation of pain
of 6 out of 10 and of pain from scale during acute pain from scale of 6 to 3
Objective: slowed movement. of 6 to 2
-facial grimace -Provide a -To aid in -knew different
-pain scale of 6 -to know different therapeutic alleviation of pain techniques in
-slowed movement techniques in environment alleviating pain
alleviating pain
V/S taken as -Encourage -To assist in -comfortably fell
follows: -comfortably fall verbalization of evaluation asleep
Temp: 37.3 asleep feelings
Rr: 21
Pr: 81 -Encourage to do -To alleviate pain
BP:120/70 diversional
activities

-Encourage rest and -To assess in

sleep alleviation of pain
 POTENTIAL NCP

Cues Nursing Diagnosis Planning Nursing Rationale Evaluation

Interventions
Objective: Risk for uterine After 8 hours of -Monitor vital signs -Alterations from After 8 hours of
infection related to nursing care, the normal may be nursing care, the
-NSD with episiotomy client will be able signs of infection client:
episiotomy to:
-Proper perineal -Appropriate self -verbalized
-used single pad for -verbalize care and hygiene care of the perineum understanding of
12 hours understanding of in postpartum risk factors
risk factors patients reduces the
-Temp. = 37 C risk of bacterial -identified
-identify invasion interventions and
interventions and demonstrate
demonstrate -Emphasized early -Circulation of techniques to
techniques to ambulation and blood is promoted prevent risk for
prevent risk for beginning postpartal through regular infection
infection exercises with movements thus it
resumption of helps in the healing
normal activities as process
tolerated

-Encourage to eat -Vit.C is known to

foods that are rich prevent infection:
in proteins and Protein is needed
Vitamin C for tissue repair and
regeneration
-Encourage to have -This promotes
enough rest and healing by reducing
sleep basal metabolic rate
and allowing
oxygen and
nutrients to be
utilized for tissue
growth, healing and
regeneration