Assessment Diagnosis Planning Nursing Rationale

Intervention
Cues/Data

Subjective: Self care After 1 hour 1. Establish To promote After nursing

deficit in of nurse- rapport cooperation intervention
She also added grooming and client the mother
that she don't 2. Assess ability The patient
dressing interaction, understand the
even have time to carry out ADLs may only
related to the mother importance of
for herself. on regular basis. require
weakness will be able good hygiene.
to improve Determine the assistance
Objective:
aspects of self- with some
her dressing
-messy hair and care that are self measures
problematic to
and nails grooming.
the patient.
uncut noted.
3. Discuss about This enables
- V/S as taken the patient to
to-do list and
as follows: how to manage know the task
she needs to
time using it.
T- 36.3 do daily and
adjust the
P- 95
time for each
R- 17 task.

BP-130/100 The patient

4. Discuss some will be able to
self care
practices and its
importance

5. Instruct the
patient to use
clothing with
larger size

Assessment Diagnosis Planning Nursing Rationale Evaluation

CUES/DATA Intervention

Subjective: Acute pain r/t After 4 hours -Establish -In order to After 4 hours
disruption of of nursing Rapport gain trust. of nursing
"Sakit gihapon skin and tissue intervention, intervention,
akong tahi" as secondary to the patient will -Provide -To alleviate the patient
verbalized by the comfort pain by
cesarean report verbalizes
patient delivery decrease of measures such promoting non decrease of
as pharmacologic
Objective : pain from 4 to pain from 4 to
1. repositioning al pain 1.
and quiet management.
-Tranverse
environment -Goal is met
incision is
evident. -Encourage
-To distract
diversional
attention and
-The pain is activities such
reduce
scaled by ate as listening to
tension.
music
jessel as 4 out
of 10. -Instruct
patient to use -To reduce
supportive pain especially
materials such when moving.
as binder

-Encourage the
patient to do -It promotes
deep breathing healing of
exercise and surgical
demonstrating wounds
it.