Assessment Subjective: Masakit pa rin hanggang ngayon ung tahi ko..

as verbalized by the patient Objective: - pain P-pain is much felt when moving Q- sharp pain R- abdominal pain, does not radiate S- 6/10 pain scale T- pain was felt after an hour after the surgery - sleep disturbance -grimace -pallor

Nursing Diagnosis Acute pain related to surgical incision secondary to episiotomy as evidenced by pain scale of 6/10

Scientific Explanation

Planning Discharge outcome: Prior to discharge, the client will be able to report pain is relieve or control from 6/10 to 0/10

Intervention
Independent: - Assess pain through self report with the use of Numeric Rating Scale

Rationale

Evaluation Discharge outcome: Prior to discharge, the client will be able to report pain is relieved or controlled from 6/10 to 0/10

Short term outcome: After 8 hours of nursing intervention, the client will be able to: - decrease pain from 6/10 to 3/10 -verbalize 2-3 non pharmacologic method that relief pain

- The most reliable indicator of pain is through selfreport (ICSI, 2008). Assessing the patients current pain, pain goal, and how the pain interferes with activities will help the nurse develop a plan for managing pain (Akyol, Karayurt, & Salmond, 2009). The study found that patients who received the therapies required less opioids and reported lower levels of anxiety on postoperative day 2 (Pellino et al., 2005).

- Provide the patient with non pharmacologic interventions include:

Short term outcome: After 8 hours of nursing intervention, the client will be able to: - decreased pain from 6/10 to 3/10 -verbalized 2-3 non pharmacologic method that relief pain

cold application (cold packs)

- Adie, Naylor, and Harris (2009) found that patients who used cold application saw a significant reduction in pain on postoperative day 2

relaxation, imagery, and music therapy

- Music has been reported to have a positive impact on pain. A review of the effects of music on pain found that postoperative pain intensity was decreased by 0.5units (Cepeda, Carr, Lau, & Alvarez, 2006). - Postoperative complications are prevented with ambulation. Teach the patient how to use assistive devices and adhere to any weight-bearing restrictions that are ordered. The American Association of Orthopedic Surgeons (AAOS) supports mobilization and ambulation by the first day postoperative (Johanson et al., 2009). - Exercise can increase or maintain range of motion, increase blood flow,

- assist the patient in early ambulation

- Instruct to perform

ROM with frequent resting between ambulations and exercise

prevent muscle guarding, spasms, and contractures. Rest or immobilization may reduce edema formation. - Repositioning increases blood flow and prevents muscle guarding and spasms, which reduces acute pain or prevents additional pain. - Acute pain is best managed using pharmacologic agents (ICSI, 2008). Analgesia appears to be the best way to begin pain management.

- Position in semi fowler. Reposition frequently

Collaborative: - Administer analgesics or any pain reliever as prescribed by the patient