NURSING CARE PLAN

ASSESSMENT/ NURSING CASE PLAN INTERVENTIO RATIONALE EVALUATIO

CUES DIAGNOSIS BACKGROUND NS N

Subjective: Acute pain Caesarean Goal: Independent Goal’s Met.

“Masakit ang related to delivery is the To alleviate • Assess pain • Assessment of
tahi ko.” surgical surgical and relieve characteristic pain experience is After 7 hours
incision as removal of the pain s the first step in of nursing
manifested infant from the experienced planning pain interventions
Objective: by facial uterus through by the patient management , the pain
• Facial mask grimace an incision strategies. experienced
of pain made in the Outcome by the
• Diaphoresis abdominal wall Criteria: • Observe or • Attention to patient was
• Guarding and the uterus. monitor signs associated signs relieved with
behavior Size and After 7 hours and may help the a pain scale
• Pricking pain location of the of nursing symptoms nurse in of 2/10.
with the pain incision vary, interventions: associated evaluating pain.
level of 7/10 but abdominal • The with pain and
at the and uterine patient will vital signs.
hypogastric incisions of verbalize
area choice are low adequate • Provide • This promotes
and horizontal. relief of comfort non-
v/s checked as Vertical pain. measures pharmacological
follows: incisions may • The (e.g. touch, pain
be necessary patient will repositioning, management.
BP: 180/100 for quicker follow use of
mmHg procedures, the prescribed heat/cold
PR: 82 bpm presence of pharmacol packs,
RR: 22 adhesions and o-gical nurse’s
cycles/min. other regimen. presence),
T: 37.9˚C complications. quiet
environment
and calm
activities. • Relieves muscle
and emotional
• Encourage tension.
use of
relaxation
technique
like deep
breathing
exercises. • Analgesics are
administered to
Dependent maintain
• Administer acceptable level
analgesics or of pain.
nonsteroidal
anti-