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CUES/EVIDENCES
NURSING
DIAGNOSIS
NURSING
INTERVENTIONS
Subjective:
-Verbalized: sakit na kaau, lami na
iutong
-Verbalized: dili na nako
maagwanta ang kasakit.
-Rated pain as 10 (in a scale of 1-10
with 10 as the most painful and 0 as
the least)
Objective:
-Vital signs
T= 36.5 C
PR= 74 bpm regular, and bounding
RR= 20 cpm, regular and effortless
BP= 110/80 mmHg weeks
Independent:
1. Monitor V/S
OBJECTIVES:
Within our care during the delivery
process, the client shall have reduced
perception of pain as evidenced by:
CUES /
EVIDENCES
Objective:
Vital signs:
T= 36.5 C
PR= 74 bpm regular, and
bounding
NURSING
DIAGNOSIS
Risk for infection related to presence of
episiotomy and tissue trauma
OBJECTIVES:
Within our care during delivery process,
the client will have no signs and
symptoms of infection as evidenced by:
NURSING
INTERVENTIONS
Independent:
1. Assess the condition of episiotomy
site.
2. Monitor amount of swelling,
RATIONALE
EVALUATION
EVALUATION
At the end of our care during
delivery process, the goal
was partially met as
evidenced by:
1. Vital signs were not taken
1.
V/S will remain or be
within normal range (T=36.5-37.5 C;
PR=60-100 BPM; RR=12-20 CPM;
Bp= 120-140/60-90 mmHg
2.
Episiorrhaphy done
without any signs of infection
3.
Primigravida
Presence of bulging,
swelling, edematous perineum
due to pressure of presenting
part of the fetus
Intact suture
4.
Minimal swelling and
redness in the perineum
episiotomy.
3. Prevent contamination of the
sterile field this minimizing further
complications.
4. To avoid further injury of the
episiotomy wound.
5.
No foul odor in the
perineum
6.
No exudates passes
7.
Remain in lithotomy
position
8.
Observance of sterile
technique by the physician and
student nurses