NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain related to tissue After 2-3 hours of nursing Independent: Goal met. After 3 hours of
injury secondary to surgical interventions, patient will nursing intervention, the
“Masakit ang tahi ko” as incision; Caesarian Section verbalize decrease intensity 1. Establish rapport 1. To have a good nurse- client verbalized pain
verbalized by the client. of pain from 8/10 to 4/10. client relationship decreased from a scale of
8/10 to 4/10 as evidenced
Pain Scale: 8/10 2. Monitor vital signs 2. To establish a baseline by (-) facial grimace, (-)
data guarding behavior.
Objective:
3. Assess quality, 3. To establish baseline
Facial grimace characteristics, and data for comparison in
Guarding behavior severity of pain making evaluation and
to assess for possible
Vital signs taken as internal bleeding.
follows:
BP: 100/70 4. Provide comfortable 4. Calm environment
T: 36.1 C environment – change helps to decrease the
P: 88 bed linens anxiety of the patient
R: 23 and promote likelihood
of decreasing pain.

5. Instruct to put pillow 5. To check for diastasis

on the abdomen when recti and protect the
coughing or moving area of the incision to
improve comfort

Dependent:
1. Administer Tramadol 1. Pharmacologic
as ordered treatment to relieve
pain