Patient’s Name: Ms. Helen Alfeche Age: 25 years old Ward No.: Gyne 6 Name of Physician: Dr.

Name of Physician: Dr. Tremedal, Dr. Tan-Ting

Complaints: Regular Uterine Contractions Sex: Female Impression/Diagnosis: Pregnancy Uterine, term, cephalic,
delivered spontaneously a live male neonate

BRUNSWICK LENS MODEL

measures to:
I. risk for infection I. reduce risk for infection
- presence of first degree laceration - stress proper handwashing techniques by all
- perineal trauma caregivers between therapies / clients
- insufficient knowledge to avoid exposure to - change dressings as needed / indicated
pathogens - provide regular catheter / perineal care
A case of Ms. Helen
- V/S: PR-94 bpm RR-24 bpm BP-120/90 mmHg - emphasize necessity of taking antibiotics
Alfeche for the first
- “wala ko kahibaw unsaon paglikay sa inpeksyon.” - review individual nutritional needs, 60 % - 80 %
time at CDU-H who
appropriate exercises, and need for rest resolution of
just gave birth and is
physiologic and
experiencing pain
II. Altered comfort II. alleviate pain potential
due to the perineal
- facial grimace - provide comfort measures (back rub, change problems
lacerations
- slow, guarded behavior of position, use of heat/ cold)
- pain is 4 based on the 0 to 10 pain scale I. Risk for
- instruct use of relaxation exercises such as
- moaning infection related tofocused breathing, individualized taps
- patient describes pain in the perineal area as presence of perineal - encourage diversional activities
recurrent, occurring at 10 seconds, gnawing and is laceration - encourage adequate rest periods
aggravated during movement, relieved by bed rest II. Altered - administer analgesics as indicated to maximal
and analgesics comfort: pain relateddosage as needed
- “sakit kayo akong tahi labi na inig lihok to presence of perineal
nako.” laceration
II. Altered family process III. Altered III. direct energies in a purposeful manner
- mother showing concern for baby family process related - observe pattern of communication in the
- anxiety to incorporation of family
- fear newborn to family - listen for expressions
- facial tension - acknowledge difficulties and realities of
- attention of patient solely focused on the situation
baby - stress importance of continuous, open
- “Ma-usab na jud ni among panlihok sa dialogue
balay” - involve family in planning for future
ACTUAL STATE OF
PATIENT’S CONDITION CUES DIAGNOSIS NURSING INTERVENTIONS DESIRED OUTCOME

OBJECTIVES GOAL
After 8 hours of nurse-patient interaction, the patient will After 5 days of rendering holistic
be able to: nursing care, the patient will be able to
1. gain and apply knowledge on preventing infection display improvement of health
2. report that the pain has alleviated condition and manifest absence of any
3. understand the changes of having a new family complication
member and apply the knowledge to improve
relationships