ASSESSMENT
Subjective:
 38 years old
 Watery
vaginal
discharge
Objective:
 33 weeks
AOG
 Difficulty
conceiving
due to history
of fibroids
 Premature
rupture of
membranes
 Fully dilated
cervix
 4th degree
perineal tear
General Survey:
 Isolated
 Depressed
 Anxious
 In pain
NURSING
ANALYSIS
Perineal tear is a
tear or injury to the
skin and/or muscles
between the vaginal
introitus and the
anal opening.
A complete
disruption of the
anal sphincter
including the anal
epithelium causes a
fourth-degree or
complete perineal
tear.
NURSING
DIAGNOSIS
Fecal incontinence
and urinary urgency
due to 4th degree
perineal tear
secondary to
trauma
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Short term : After
1 hour of nursing
interventions
 Pt will
verbalize the
intensity of
pain as less
than 5 in a
pain scale
with 10 as the
highest and 0
as the lowest
 Pt. will
maintain
stable vital
signs
Independent:
1. Monitor vital
signs every 15
minutes
2. Encourage the
patient to void
3. Provide comfort
measures such as
massages,
perineal care,
changing of
patient position,
application of
hot or cold
compress, as
well as
therapeutic
touches during
contraction
Independent:
1. To obtain
baseline data
2. Voiding may
enhance progress
of labor and
reduce the risk of
bladder
perforation
3. These measures
promote hygiene,
relaxation and
physical comfort.
Therapeutic
touches also
promote release
of endorphins
which is known to
decrease pain
Short term : After
1 hour of nursing
interventions
 Pt now rates
her pain as 4
in a pain
scale with 10
as the highest
and 0 as the
lowest
 Pt.
maintained
stable vital
signs
Short term
Dependent
1. Administer local
anesthetic
(Bupivacaine)
Short term
Dependent
1. To provide pain
relief
Long term:
After 6 weeks of
nursing
interventions
 Pt. will be
albe to sit,
walk, urinate
and defecate
properly
without pain
Long term
Dependent
1. Provide pain
relief
medications
(NSAIDS)
2. Offer
perineoplasty or
perineorrhaphy
Long term
Dependent
1. To provide pain
relief
2. To return the
rectum back in its
original position
and repair other
deformities
Long term:
After 6 weeks of
nursing
interventions
 Pt. is now
able to sit,
walk, urinate
and defecate
properly
without pain