XI.

NURSING CARE PLAN

Post-operative NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME

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

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

- For pulmonary
ventilation, especially
- Instructed when exercising, and
patient to do deep to relieve stress and
breathing and promote relaxation.
coughing exercise.
- To promote
circulation, prevent
venous stasis,
- Provided prevent pressure on
diversionary the operative site.
activities. Initiate
ankle pumping,
active lower
extremity ROM, and -Relieves pain felt by
walking the patient

Collaborative:
- Administer
analgesic as per
doctor’s order.
ASSESSMENT DIAGNOSIS NURSING PLANNING INTERVENTION RATIONALE EVALUATION
ANALYSIS
Subjective: Risk for Due to an STG: Independent
- none infection related elective After 4 hours of -Monitor vital -To establish a Patient is
inadequate cesarean nursing signs baseline data expected to be
Objective: primary section, intervention, free of
- dressing dry defenses patient’s skin patient will be -Inspect dressing -Moist from infection, as
and intact secondary to and tissue were able to and perform drainage can be a evidenced by
-V/S taken as surgical incision mechanically understand wound care source of infection normal vital
follows: interrupted. causative signs and
T: 37.3 Thus, the factors, identify - Monitor white - Rising WBC absence of
P: 80 wound is at risk signs of blood count (WB indicates body’s purulent
R: 19 of developing infection and efforts to combat drainage from
BP: 120/80 infection. report them to pathogens; wounds,
health care normal values: incisions, and
provider 4000 to 11,000 tubes.
accordingly. mm3

LTG: - Monitor -these are signs

After 2-3 days Elevated of infection
of nursing temperature,
intervention, Redness,
patient will swelling,
achieve timely increased pain,
wound healing, or purulent
be free of drainage at
purulent incisions
drainage or
erythema, be - Wash hands -Friction and
afebrile and be and teach other running water
free of infection. caregivers to effectively remove
wash hands microorganisms
before contact from hands.
with patient and Washing between
between procedures
procedures with reduces the risk of
patient. transmitting
pathogens from
one area of the
body to another

- Encourage fluid - Fluids promote

intake of 2000 ml diluted urine and
to 3000 ml of frequent emptying
water per day of bladder;
(unless reducing stasis of
contraindicated). urine, in turn,
reduces risk of
bladder infection
or urinary tract
infection (UTI).

- Encourage - These measures

coughing and reduce stasis of
deep breathing; secretions in the
consider use of lungs and
incentive bronchial tree.
spirometer. When stasis
occurs, pathogens
can cause upper
respiratory
infections,
including
pneumonia.

Independent: -Antibiotics have

 -Administer bactericidal effect
antibiotics that combats
pathogens

NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Objective Cues:
• Patient has Risk for Short Term INDEPENDENT After 8º of
not yet constipation r/t Goal: INTERVENTIONS: nursing
eliminated post pregnancy • Ascertain normal • This is to interventions, the
since 2° cesarean Within 8º of bowel functioning of determine the patient was able
delivery the patient, about normal bowel
section nursing to identify
• Absence of how many times a pattern
interventions, measures to
bruit sounds day does she
• Normal the patient will prevent infection
defecate • To increase the as manifested by
pattern of be able to • Encourage intake of bulk of the
bowel has demonstrate foods rich in fiber client’s
stool and
not yet behaviors or such as fruits facilitate the verbalization of:
returned lifestyle changes passage “Iinom ako ng
to prevent through the maraming tubig
developing colon at kakain ng
problem • Promote adequate • To promote prutas para
fluid intake. moist soft stool makadumi ako.”
Suggest drinking of
warm fluids,
especially in the
Long Term
morning to
Goal: stimulate peristalsis • To stimulate
• Encourage contractions of
Within 3 days of ambulation such as the intestines
nursing walking within and prevent
interventions, individual limits post operative
the patient will complications
be able to • However, since she • To avoid stress
has had cesarean, on the
maintain usual
also encourage cesarean
pattern of bowel incision/ wound
adequate rest
functioning periods

COLLABORATIVE:

• Administer bulk- • To promote

forming agents or defecation
stool softeners such
as laxatives as
indicated or
prescribed by the
physician