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NCP (Post-Partum Pain)

The patient reported pain from a laceration on their face. On examination, the patient had diaphoresis, facial grimacing, and rated their pain an 8 out of 10. The goals were to decrease the patient's pain to 6 out of 10 by instructing them to take medications as prescribed and positioning them comfortably. The patient's vitals were monitored and they were encouraged to eat nutritious foods and maintain proper hygiene to aid healing and recovery.

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33K views1 page

NCP (Post-Partum Pain)

The patient reported pain from a laceration on their face. On examination, the patient had diaphoresis, facial grimacing, and rated their pain an 8 out of 10. The goals were to decrease the patient's pain to 6 out of 10 by instructing them to take medications as prescribed and positioning them comfortably. The patient's vitals were monitored and they were encouraged to eat nutritious foods and maintain proper hygiene to aid healing and recovery.

Uploaded by

allure*20
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Assessment Nursing Analysis Planning/Objectives Intervention Rationale Evaluation

Subjective: Pain r/t laceration  To be able to  Instruct the pt.  To provide the  Encourage to
“ Sumasakit ang of the delicate decrease the level of to take the pt. comfort if the eat nutritious
tahi ko”, as tissues AMB facial pain from 8 to 6 medications on pain has foods.
verbalized by the grimace. using pain scale of 10 time. decreased from  Emphasized the
pt. to 1. the pain scale goal. importance of
Impaired skin/  In order to heal proper hygiene.
Objective: tissue integrity or fast recovery
 conscious and may be r/t after taking
cooperative mechanical medications.
V/S interruption of  To provide  Positioned pt.
T → 36. 8•C skin/tissues, comfort. comfortably. To have comfort
P → 66 beats/min altered  Linens from the pain.
R → 14 breaths/ circulation, stretched for
min effects of more comfort.
BP→ 110/80 medication,
 diaphoresis accumulation of  Advised the
 (+) pain drainage, and  Keep back dry.  To keep away mother to
 face connotes altered metabolic from getting a breastfeed.
pain state, possibly disease such as
evidenced by  V/S taken & be pneumonia.
Diagnosis: disruption of skin recorded.  To monitor if
 Few hr. PTA→ surface/ layers V/S has changed
(+) lumbrosacral and tissues. from its baseline  Nrsg. Care
pain. and to assess the rendered.
pt.’s condition.  discharged.

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