NURSING CARE PLAN

ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM

Subjective: The patient had given STO: Dx: STO:

cesarean birth which led
 "Di ako her to feel the pain of After 4 hours of effective  Identified the cause of pain.  To know what interventions (Goal Met)
makagalaw ng incision closure after nursing interventions, the to do.
maayos kasi patient will be able to  Monitored vital signs After 4 hours of
the cesarean
masakit yung experience lesser pain and  To establish a baseline data. nursing
delivery.
opera ko". above a tolerable level as intervention, the
The pain is an unpleasant  Assessed quality, characteristics,  To establish baseline data for
 Reported pain manifested by: patient was able to
sensory and emotional severity of pain. comparison in making
with intensity 9 experience lesser
experience associated with evaluation.
on the a. Pain scale of at least Tx: pain and above a
actual or potential tissue
standardized pain 4/10 tolerable level as
damage, or describe in  Advised patient to do breathing
scale where 1 has b. No facial grimace manifested by:
terms of such damage. It is exercises
the least pain and c. Slight irritability  To decrease discomfort
a sudden or slow onset of - Pain scale of 4/10
10 has the severe any intensity from mild to  Instructed patient to us
pain. severe with an anticipated supportive materials such as - No facial grimace
 To reduce pain especially
or predictable end. binder noted
Objective: when moving
(NANDA)
 Administered analgesic as - Calm and
 Facial expression
ordered by physician cooperative
of pain / grimace  To relieve the pain
 Guarding/
protective
behavior SOURCE: LTO:
 Positioning to
Doenges, M.E., Edx: (Goal Met)
ease pain
Moorhouse, M.F., & Murr, LTO:
 Irritability After 72 hours of
A.C. (2012). Nurse’s  Encouraged fluid intake of 2000
 Discomfort After 72 hours of effective effective nursing
Pocket Guide (14th ed.). ml to 3000 ml of water per day
 V/S taken as nursing interventions, the  Fluids promote diluted urine interventions, the
F.A. Davis. (unless contraindicated).
follows: patient will: and frequent emptying of patient achieved
bladder; reducing stasis of
 -BP: 90/70 a. Achieve timely wound urine, in turn, reduces risk of timely wound
-PR: 80 healing bladder infection or urinary healing, free of
-RR: 15 b. Free of infection tract infection (UTI). infection and was
-T: 36.7 c. Able to move without able to move
-SPO2: 96 much assistance from  To promotes healing of without much
 Encouraged patient to do Deep surgical wounds
others assistance from
Breathing Exercise by
others.
Nursing Diagnosis: demonstrating how to do it
(every 4 hour daily with 5-10
ACUTE PAIN related breaths during exercise).
to surgical incision due
to cesarean birth as  Encouraged ambulation such as
walking within individual limits  To stimulate contractions of
evidenced by facial
the intestines and prevent
grimace with a pain
post-operative complications
scale of 9.
 Educated on adequate rest  To avoid stress on the
periods cesarean incision/ wound