ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUAT

THE PROBLEM

Subjective: The patient had post- STO: Dx: STO:

operative pain in the
"Masakit yung tahi hypogastric region Within 30 minutes-1  Observed guarding  To assess the onset of (Goal Me
ko kapag due to sutures and hour of effective behavior of the pain and the area
gumagalaw ako". nursing interventions, abdominal region and where the pain starts Within
incisions made.
the patient will be expressive behavior while minutes-1
Objective: able to: moving or changing of eff
Cesarean delivery nursing
positions
 Guarding (also called a a) verbalize decrease interventi
 Pain can limit the
behavior cesarean section or C- in pain rated to 5/10  Assessed ability to the p
patient's ability to
 Needs section) is the perform activities of daily verbalized
participate in self-care
assistance surgical delivery of a b) relaxed facial living. decrease
and function daily
with activities expressions and body pain rat
baby by an incision activities
like rising positioning. 4/10, r
through the mother's independently.
from bed facial
abdomen (belly) and c) participate in
 Pain rates  To determine degree of expressio
uterus(womb). This recommended
6/10  Measured pain through pain. and
procedure is done relaxation techniques
numeric rating scale for
if pain sets again. positionin
when it is determined severity
while r
to be a safer method
and is a
than a vaginal
Nursing Tx: participat
delivery for the LTO:
Diagnosis:  Help conserve energy recomme
mother, baby, or  Assisted with activities of and assist in daily relaxation
Within 24 hours of
PAIN related to both. daily living and promoted activities until client technique
effective nursing
post-operative comfort and rest. can independently do it when pai
In a cesarean interventions, the
procedure as again.
delivery, an incision patient will:
manifested by  Fear and anxiety can
facial grimace, (cut) is made in the decrease the client’s
a) perform relaxation  Implement measures to
guarding behavior skin and into the techniques threshold and
reduce fear and anxiety LTO:
and verbal report uterus at the lower independently when tolerance for pain and
of pain felt in the part of the mother’s pain sets. thereby heighten the
hypogastric region abdomen. The b) able to rest, display perception of pain. In (Goal Me
rated as 6/10. incision in the skin reduced tension, and addition, pain
sleeps comfortably. management methods Within 24
may be vertical
are not as effective if of eff
(longitudinal) or c)verbalize nursing
client is tense and
transverse nonpharmacological interventi
unable to relax.
(horizontal), and the methods provided the patie
incision in the uterus relief able
 Increase in the normal
may be vertical or value of respiratory independ
transverse. d) able to ambulate  Monitored vital signs like do rela
rate, pulse rate, blood
and do daily activites respiration rate, blood technique
A transverse incision pressure, oxygen
with minimal pressure, pulse rate, deep-brea
saturation and
extends across the assistance oxygen saturation and asks
temperature can be a
pubic hairline, temperature with each minimal
result of pain and
whereas, a vertical onset of pain assistanc
anxiety
incision extends from when risin
the navel to the pubic changing
hairline. A transverse  Walking promotes blo position i
uterine incision is od flow of oxygen able to d
 Assisted client to
used most often, throughout the body activities
ambulate
because it heals well while maintaining independ
and there is less normal breathing like goin
bleeding. Transverse functions. Ambulation the rest
stimulates circulation alone,
uterine incisions also
which can help stop comfortab
increase the chance
the development of rests w
for vaginal birth in a
stroke-causing blood any
future pregnancy. clots. Walking grimace
However, the type of improves blood flow sleeping
incision depends on which aids in quicker verbalized
the conditions of the wound healing. relaxation
mother and the fetus. exercises
 relieved p

Edx:

 If the client is well-

SOURCE/S:  Educated on energy- rested . he/she often
conservation techniques experiences decreased
https://www.stanfordchil such as encouraging pain and increased
drens.org/en/topic/defaul client to take a lot of rest effectiveness of pain
t?id=cesarean-delivery- management
92-P07768 measures.

 Encouraged to do  Deep abdominal

relexation techniques like
deep-breathing.
breathing helps
oxygenate blood which
triggers the release of
endorphins which
decrease release of
stress hormones and
slows down heart rate.

 Encouraged to increase  Packed red blood cells

the consumption of foods increase oxygen-
high in dietary iron such carrying capacity of
as malunggay, spinach the blood thereby
and liver. And also the reducing fatigue and
intake of foods high in promoting healing and
folic acid and vitamin B12 rest.s
such as green leafy
vegetables and dairy
products.

 Instructed patient in ways

 to monitor responses to  All these measures can
activity and significant help the patient
signs/symptoms that may conserve energy and
indicate the need to alter reduce fatigue
activity level.

 Advised to report
 To ensure timely
promptly any untoward
intervention, prevent
feelings and concerns
complications and
about pain.
assist client’s needs.

 Helps replenish the

 Educated to drink plenty
client’s energy and
of water every after onset
also help cool down
of pain
body temperature,
decrease heart and
respiratory rate