NEEDS/PROB NURSING SCIENTIFIC BASIS/ OBJECTIVES OF CARE NURSING ACTION RATIONALE
LEMS DIAGNOSIS SIGNIFICANCE
CUES
Objective Alteration in Episiotomy, the incision of the After 8 hours Independent Measures
Cues: Comfort: Pain perineum during the last part of of nursing to:
-facial related to the second stage of labour or interventions assess reports of -to assess the
grimace uterine delivery is still considered a , the patient level of pain felt
controversial procedure. Long- abdominal cramping
-guarded cramping due to will or pain, by the patient, to
term complications after
movement presence of demonstrate noting location, be able to know
episiotomy repair are common.
-pallor perineal sutures A large proportion of women report what nursing
duration, intensity
-apprehension suffer short-term perineal pain. pain is relieved or interventions to
(0-10 scale).
controlled. undertake.
Subjective: -
Investigate and
“Sakit kaau http://www.pelviperineology.or report changes in
nars, maglisod g/multidisciplinary/episiotomy_ pain characteristics.
ko ug lihok. ” repair_material_suturing_perine
as verbalized al_muscles.html instruct use of -This distracts
by the patient relaxation techniques the mother’s
such as focused attention and
v/s: breathing, imaging, may reduce the
BP- cds and tapes to pain and tension
80/55mmHg distract attention and felt
RR:15 reduce tension
breaths/min
PR:58 encourage rest
beats/min
Temerature:36 -Labor and
degrees Delivery used up
Celsius a lot of energy
that the mother
must now
regain, to better
cope with
presence of pain.
- To have a
encourage patient to baseline data and
report pain. as a regular
assessment tool
-to evaluate
effectivity of
nursing
note nonverbal interventions.
cues such as
restlessness,
reluctance to
move and
abdominal
guarding.
-to have a guide
to promote a
faster form of
review factors relief and
that aggravate or recovery of
alleviate pain. mother, and for
her comfort.
-to relieve pain
and to prevent
discomfort.
-this hastens the
physiological
encourage patient to and
assume position of psychological
comfort healing process
of the mother.
.
Provide comfort -for relief of the
measures. patient’s pain
-to promote a
better, faster
healing
Collaborative:
give prescribed pain-
relief medications
implement
prescribed dietary
modifications.