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SP CS

The patient reported severe pain after a cesarean section, rating it a 9/10. On assessment, she displayed signs of pain including being teary-eyed, guarding her abdomen, and having a facial grimace. Her vital signs were within normal limits. The nursing care plan was to provide comfort measures like changing bed linens, establish rapport, monitor her vital signs and pain level, and instruct her on deep breathing exercises to help decrease her pain to a 3/10 within 2 hours.

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Khan Hans
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621 views4 pages

SP CS

The patient reported severe pain after a cesarean section, rating it a 9/10. On assessment, she displayed signs of pain including being teary-eyed, guarding her abdomen, and having a facial grimace. Her vital signs were within normal limits. The nursing care plan was to provide comfort measures like changing bed linens, establish rapport, monitor her vital signs and pain level, and instruct her on deep breathing exercises to help decrease her pain to a 3/10 within 2 hours.

Uploaded by

Khan Hans
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

S/P CESAREAN SECTION

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME


Subjective: Acute pain After 1-2hr Independent: Goal met.
r/t of nursing After 2hrs of
“Sobrang
disruption of intervention, nursing
sakitng tahi
skin and patient will - Established rapport. -To have a intervention,
ko,” as
tissue verbalize good nurse- the patient
verbalized by
secondary to decrease client verbalized
the patient.
cesarean intensity of relationship pain
section. pain from decreased
8/10 to 3/10. from a scale
Objective: - Monitored vital -To establish of 8/10 – 3/20
signs. a baseline
-Pain scale= as evidenced
data by
9/10
-Teary eyed (-) facial
- Assessed quality, -To establish
characteristics, grimace
-guarding baseline data
severity of pain. for (-) guarding
behavior
comparison in behavior.
-facial grimace making
Frequent
-Irritable evaluation
small talks
and to assess
-Pale palpebral with
for possible
conjunctiva significant
internal
others
-Skin warm to bleeding.
touch -Calm
- Provided environment
comfortable
- V/S taken as environment helps to
– changed decrease the
follows: bed linens anxiety of the
BP= 110/80 and turned patient and
on the fan. promote
PR= 80 likelihood of
RR= 22 decreasing
pain.
T= 37.6

- Instructed to put - To check for


pillow on the diastasis recti
abdomen when and protect
coughing or the area of the
moving. incision to
improve
comfort. And
to initiate
nonstressful
muscle-
setting
techniques
and progress
as tolerated,
based on the
degree of
separation.

- Instructed patient to
- For
do deep breathing
pulmonary
and coughing ventilation,
exercise. especially
when
exercising,
and to relieve
stress and
promote
relaxation.

- Provided
diversionary - To promote
activities. Initiate circulation,
ankle pumping, prevent
active lower venous stasis,
extremity ROM, prevent
and walking pressure on
the operative
site.

Collaborative:
- Administer
-Relieves
analgesic as per
pain felt by
doctor’s order.
the patient

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