NEEDS /

NURSING
PROBLEMS DIAGNOSI
CUES
S

I.
Physiologic
overload:
Acute pain
Objective
cues:
-facial
grimace
-weakness
-guarded
movements
-limited
movements
-little
difficulty in
ambulation
O after
caesarean
delivery
L lower
abdomen
D 5-10
minutes
C gnawing
pain
A upon
movement
R
restriction
of
movements
T
administrati
on of pain
reliever

Alteration
in comfort:
acute pain
related to
post
operative
surgical
incision

SCIENTIFI
C
BASIS /
SIGNIFICA
NCE
Pain is an
unpleasant
sensory and
emotional
experience
arising from
actual
tissue
damage, in
relation to
CS delivery,
a repeat
low
segment
transverse
Cesarean
Section was
done to the
patient.

OBJECTIVE
OF
CARE

NURSING
ACTIONS

After 8
hours of
SN-patient
interaction,
the patient
will be able
to:

Measures to:
alleviate
pain

Decrease
pain score
from 5/10
to 3/10

RATIONAL
E

to reduce
pressure of
pain

1. provide
nonpharmacolog
ical
measures for
relief such as
relaxation
techniques
reduces the
possibility
2. eliminate
of
vasoconstrict experiencin
ing activities g pain
that may
aggravate
pain
to promote
3. maintain
relaxation
bed rest and
rest periods
to promote
4. provide a
relaxation
quiet
environment to reduce or
control pain
5. administer
analgesics
as indicated

Subjective
cues:
Sakit man
panagsa
akong
tinahian,
dai, as
verbalized
by the
patient.
Pain score
5/10

Source:
Medical
Surgical
Nursing 12th
Edition

Source:
Nursing
Care Plans
5th Edition
Source:
Nursing Care
Plans 5th
Edition