Assessment

Nursing Diagnosis Acute pain related to labor and delivery manifested by perineal pain.

Scientific Analysis Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.

Plan of Care

Nursing Intervention

Rationale

Evaluation

Subjective: Masakit po ang puerta ko.. Objective: Protective gesture, grimace, moaning and irritability.

Goal: After 30 minutes of nursing intervention, the patient will be able to verbalize the pain in her perineal area, and is relieved and controlled.

1. Obtain clients assessment of pain to include location, characteristics, onset and duration, frequency, quality, intensity and precipitating or aggravating factors. Reassess each time pain occurs/is reported. 2. Accept clients description of pain. Acknowledge the pain experience and convey acceptance of clients response to pain. 3. Use pain rating scale appropriate for age and condition (e.g., 0-10 scale; facial expression scale [pediatric, nonverbal]; pain assessment scale for dementing elderly [PADE]; behavioral pain scale [BPS].

1. To rule out worsening of underlying condition or development of complications.

2. Pain is a subjective experience and cannot be felt by others.

After 30 minutes of nursing intervention, the client can describe and rate the pain in her perineal area, and is relieved and controlled.

3. For easy identifying of the intensity of the pain felt by the client.

Objective: Cognitive: Describes the pain that she feels in her perineal area.

1. Ascertain clients knowledge of and expectations about pain management. 2. Review procedures and expectations including when treatment may cause pain.

1. to know the true feeling of pain.

2. to reduce concern of the unknown and associated muscle tension. 3. to lessen the pain the she/he feels.

3. Identify ways of avoiding or minimizing pain.

Psychomotor: Demonstrate use of relaxation skills and diversional activites as indicated for individual situation.

1. Provide for individualized physical therapy or exercise program that can be continued by the client after discharge. 2. Provide comfort measures (e.g., touch, repositioning, use of heat or cold packs, nurses presence), quiet environment, and calm activities. 3. Encourage diversional activities. 1. Observe non-verbal cues and pain behaviors(e.g., how client walks, holds body, sits; facial expression; cool fingertips/toes, which can mean constricted blood vessels) and other objective Defining characteristics, as noted, especially in persons who cannot communicate verbally. 2. Accepting clients attitude toward pain and use of pain medications. 3. Explain and verbalize the feelings the he/she feels.

1. Promotes active, rather than passive, role and enhances sense of control. 2. to promote nonpharmacological pain management.

Affective: Encourage verbalization of feelings about pain.

3. to divert attention and forget pain. 1. Observations may not be congruent ith verbal reports or may be only indicator present when clients is unable to verbalize.

2. to prevent any other stimulis to feel the pain. 3. to obtain specific and accurate measure of pain.

Emmanuel John C. Ramos 3-C