Name of the Patient: SAMA Sex: Female

Case Number: 265455 GTPAL: G1P0

Age: 19 AOG: 37-38 weeks

PLANNING &
NURSING NURSING
ASSESMENT INFERENCE DESIRED RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
OUTCOMES

Subjective: Acute pain Episiotomy is After 8 hours of 1. Monitor 1. To obtain After 8 hours of
Client verbalized related to surgical needed if nursing patient’s baseline nursing
“Ang sakit ng tahi incision intervention, vital signs data intervention,
ko.” secondary to The baby does
episiotomy not have enough Vital signs of the 2. Provide an 2. Reduces Patient’s vital
Objective: wound oxygen (fetal client in normal ice pack, if swelling signs remain in
Vital Signs distress) range client insist and pain normal range
BP: 110/80 BP:110-140/60- BP: 110/80
BT: 36.5 °C Complicated 90 3. Assess 3. To BT: 36.9
HR: 80bpm birth, such as BT: 36.5 – 37.5°C patient’s determine HR: 80bpm
RR: 20 when the baby is HR: 60-100 bpm general deviations RR: 18
positioned bottom RR: 12-20 health from
Client pain rate: or feet first condition normal Client verbalized,
5/10 (breech) or when Client’s and “Masakit yung
the baby’s acknowledgement obtain tahi ko pero
Grimace shoulders are of the pain as subjective kailangan eh.”
trapped (shoulder normal. cues
Positions herself dystocia) Client verbalized,
to ease the pain Client’s “May sakit pa
Long pushing verbalization of pero
stage of labor reduced pain. makakalakad
naman na ako.”
Forceps or
vacuum delivery

Large baby

Preterm baby