NURSING CARE PLAN

S/P CESAREAN SECTION

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME

Subjective: Acute pain After 1-2hr Independent: Goal met.
r/t of nursing After 2hrs of
“Sobrang
disruption of intervention, nursing
sakitng tahi
skin and patient will - Established rapport. -To have a intervention,
ko,” as
tissue verbalize good nurse- the patient
verbalized by
secondary to decrease client verbalized
the patient.
cesarean intensity of relationship pain
section. pain from decreased
8/10 to 3/10. from a scale
Objective: - Monitored vital -To establish of 8/10 – 3/20
signs. a baseline
-Pain scale= as evidenced
data by
9/10
-Teary eyed (-) facial
- Assessed quality, -To establish
characteristics, grimace
-guarding baseline data
severity of pain. for (-) guarding
behavior
comparison in behavior.
-facial grimace making
Frequent
-Irritable evaluation
small talks
and to assess
-Pale palpebral with
for possible
conjunctiva significant
internal
others
-Skin warm to bleeding.
touch -Calm
- Provided environment
comfortable
- V/S taken as environment helps to
– changed decrease the
follows: bed linens anxiety of the
BP= 110/80 and turned patient and
on the fan. promote
PR= 80 likelihood of
RR= 22 decreasing
pain.
T= 37.6

- Instructed to put - To check for

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

- Instructed patient to
- For
do deep breathing
pulmonary
 and coughing ventilation,
exercise. especially
when
exercising,
and to relieve
stress and
promote
relaxation.

- Provided
diversionary - To promote
activities. Initiate circulation,
ankle pumping, prevent
active lower venous stasis,
extremity ROM, prevent
and walking pressure on
the operative
site.

Collaborative:
- Administer
-Relieves
analgesic as per
pain felt by
doctor’s order.
the patient