NCP FOR CAESARIAN DELIVERY (BREECH PRESENTATION)

CUES/ASSESSMENT NSG.DIAGNOSIS OBJECTIVE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Cues: Acute pain At the end of my By the 1 hour of Independent:
“Makulog asin related to nursing my nursing
maluya pa an abdominal intervention of 8 intervention the
sakong pagmate incision hours duty the client will:  Establish  To easily gain  At the end of
dahil sa paghiwa secondary to patient will be  Report pain rapport to cooperation from the shift goal
kan tulak ko” as surgery able to report intensity the client the patient. is met as
verbalized by the pain is relieved from 4 to 6 evidenced
patient and controlled. will decrease by the
at 2 to 3  To have baseline patient has
Objective Cues from 0 to 10  Monitor the data and for able to
>Temp:____ 0 C pain scale. vital signs comparison of manage
>PR:_____bpm  Participate in future data pain,
>RR:_____cpm demonstratin  To enhance relieved and
>BP:_____mm/Hg g techniques patient’s self- controlled
>Rated pain as 4 to to relieve esteem and to from 4 to 6
6 out of 10 pain pain  Perform provide comfort to to 2 to 3 on
scale bedside care the patient. the pain
>Pain increases  By getting the rating scale.
when move following
vigorously the information, we
incision site. are assisting in
>Wound dry, no differentiating
discharges noted  Observe and cause of pain and
> Dressing and document providing
plaster were clean location, information about
& no foul odor severity and disease
noted on the site character of progression/resolu
pain. tion, development
of complications
 Promote and effective
bedrest interventions.
 allowing  Bedrest in low-
patient to fowlers position to
assume reduce
position in intrabdominal
comfort pressure.

 Employ non-
phatmacologi
c pain  To prevent
distraction dependency on
such as medication for
Music pain.
therapy,
imagery and
etc.

MEDICATION:
 NSAID’s

 To relieve pain
immediately