Name of the Patient: Patient X

Age: 26 years’ old

Chief Complaint: Hemorrhoids

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE INDEPENDENT:
DATA: At the end of 8 hours of At the end of the 8
“Ang sakit sakit Acute pain nursing intervention the - Monitor skin color - These are hours of nursing
po ng sa parte related to patient will be able to: and temperature usually intervention the
ng butas ng postpartum and vital signs altered in patient was able to:
aking pwet and hemorrhoids as - Minimize or relieve acute pain
grabe po yung evidence by and control the - Minimized or
dugo nagsimula bleeding with the pain and decreased relieved and
to nung after pain scale of pain scale into a controlled the pain.
ko manganak 9/10 manageable level - Assess for referred - To help Pain scale 3/10
sa ikalawa for atleast 3/10 pain as appropriate determine - Verbalized
kung baby. pain below possibility of nonpharmacological
scale of 9/10 (1 - Verbalize underlying methods that
being the lowest nonpharmacological condition or provide relief.
and 10 being the methods that organ - Stabilized heart
highest) provide relief dysfunction rate within normal
as verbalized by - Stabilize heart rate requiring range.
the patient. within normal treatment RR: 15 bpm
range. - Observe nonverbal - Nonverbal
cues and pain cues may be
OBJECTIVE behaviors both Goals are met:
DATA: physiological 3/3
and
V/S taken and psychological
recorded as and may be
follows: used in
conjunction
BP: 120/90 with verbal
T: 37.3 oC cues to
PR: 88 bpm determine
RR: 26 bpm the extent of
O2Sat: 90% severity of
the problem
(+) Restlessness
(+) Guarding - Encourage patient - It helps to
Behavior to do Sitz Bath lessen any
(+) Facial mask every after pain and
(+) Irritability defecation and discomfort.
demonstrate the
proper procedure

- Instructs the - Increased

patient to increase fluid intake
fluid intake and eat and fiber-rich
food that rich in foods help to
fiber such as fruits keep stools
and vegetables soft and
prevent
straining
during
defecation.
- Advice the patient - To promote
to do perineal care comfort and
proper
hygiene

- Assist patient in - To promote

proper positioning comfort and
at bed proper rest
needed
DEPENDENT:

- Administered pain - To reduce or

medication such as relieve the
analgesics as per pain
doctor’s order
- Note and monitor - To determine
client’s response the
with the use of pain effectiveness
medications of medication
or presence
of possible
side effects
COLLABORATIVE:

- Recommended or - To decrease
employed dependency
nonpharmacological on the
interventions, medications.
methods of pain
control.
- Monitored - To identify
laboratory studies. related
causes and
implement
preventive
measures