Assessment Nursing Background Goal of Care Intervention Rationale Evaluation

Diagnosis Knowledge

Subjective Data: Acute pain Cesarean birth After 8 hours of 1. Establish  To gain trust and After 8 hours of
related to surgical delivery nursing rapport. cooperation of nursing intervention
“Masakit yung tinahi procedure as intervention the the patient. the patient
sa akin” as evidenced by patient will be able manifested increased
verbalized by the facial grimace, High effectiveness to  To know and comfort level with
patient. pain scale of 7, level of regional 2. Assess patient determine the 5/10 pain scale
restless, lethargic anesthesia - Increased condition. patients need. without facial grimace
-Pain scale: 7/10 and irritability. comfort level and irritability.
 To obtain
Abdominal incision -Clients report 3. Monitor vital baseline data.
Objective Data: reduced pain for at signs.
least 3-5/10 pain  Initial
-Facial grimace Stiches after surgery scale. 4. Assess pain assessment
severity on provides
-Restless -No facial grimace scale of 1-10 baseline &
Decreased every hour by comparison.
-Lethargic effectiveness -Slight irritability asking patient.
level of regional and most of the  How a patient
-Irritability anesthesia time is calm 5. Observe non- sits, holds body
verbal cues to or facial
BP: 100/80 mmHg assess pain. expression can
Discomfort in reveal a lot
TEMP: 36.3°C abdominal incision about how a
area patient feels.
PR: 90 bpm
 To decreased
RR: 19 cpm Acute pain 6. Reposition the patient’s pain
patient to its and make her
comfortable body
position comfortable.

 To overcome the
7. Teach non- pain.
pharmacological
techniques
(relaxation,
distraction, etc.)
 Prevent bruising,
8. Health teaching
swelling,
about the
bleeding and
surgical incision
infection.
care