DATE/SHIFT ASSESSMENT 11-23-11 7-3 Medyo sakit pa jud akong tahi as verbalized.

. Objective: Grimace face Guarding behavior Narrowed focus V/s taken as follows T-37 PR- 85 RR-20 BP-140/90 Pain scale 4 out of 10

NEED Safety and security

NURSING DIAGNOSIS Acute pain related to disruption of skin, tissue, skin integrity Rationale: Cesarean delivery is surgical removal of the infant from the uterus through an incision made in the abdominal wall and the uterus. Size and location of the incision vary but abdominal and uterine incision of choice are low and horizontal. Vertical incisions may be necessary for quicker procedures, the presence of adhesions and other complications.

PLANNING After 8 hours of nursing interventions, the patient pain will be relieved or controlled. As evidence by: Grimace face not noted Guarding behavior not noted Narrowed focus not noted.

INTERVENTIONS Independent: > Evaluate pain regularly noting characteristics, location, intensity (0-10 scale). R: Provides information about need for or effectiveness of interventions. > Identify specific activity limitations.R:Prevents undue strain on operative site. Recommend planned or progressive exercise. R: Promotes return of normal function and enhances feelings of general well being. > Schedule adequate rest periods. R: Prevents fatigue and conserves energy for healing. Review importance of nutritious diets and adequate fluid intake. R: Provides elements necessary for tissue

EVALUATION After 8 hours of nursing interventions, the patients pain is relieve As evidenced by: Grimace face not noted Guarding behavior not noted Narrowed focus not noted.

regeneration or healing. Reposition as indicated. R: May relieve pain and enhance circulation. Provide additional comfort measures like back rub R: Improves circulation, reduces muscle tension and anxiety associated with pain. Encourage use of relaxation technique like deep breathing exercises.R: Relieves muscle and emotional tension Collaborative: Administer analgesics or non steroidal antiinflammatory drugs as prescribed. R: To relieve mild or moderate pain.