Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

NURSING CARE PLAN

Patient’s Initial: R.N. Age: 19 Gender: FEMALE Date Handled: 05/02/2024

Medical Diagnosis: Postoperative CS Clinical Area: R. De C. Galvez

Chief Complaint: The client complains about Acute Pain related to surgical incision due to cesarean birth as verbalized, “Ang sakit ng tahi ko”.

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: “Ang sakit ACUTE PAIN Short Term Goal: Independent: Independent: Short Term Evaluation:
ng tahi ko”as After 30 minutes of nursing After 30 minutes of
related to surgical 1. Assess for 1. This is to aid in
verbalized by the interventions, the patient nursing intervention,
incision due to potential types understanding the
client. will be able to experience the goals were:
cesarean birth as of pain that may reason for severity
lesser pain and above a Met
evidenced by facial be affecting of pain associated
tolerable level as Partially met.
grimace with a pain client. with the client's
Objective: manifested by: Unmet
scale of 7/10. condition and point As evidenced by:
- A pain scale of toward needed
7/10 ● The patient will be interventions for ● The patient was
- Diaphoresis able to report a pain management. able to report a
- Facial decrease of pain decreased of
expression of intensity to at least pain
intensity to at
 pain/grimace 3/10. least 3/10.
- Guarding and ● The patient will be 2. Encourage the 2. Best rest, change to
protective able to verbalize a patient to low fowler’s
behavior. sense of control of bedrest, provide position, and cough ● The patient was
- Discomfort response to acute a cough pillow, pillow will reduce able to
situations and a help the patient intra-abdominal verbalized a
positive outlook for assume a pressure to sense of control
Vital Signs: the future. position of incision. of response to
BP: 110/70 comfort in bed. acute situations
Temperature: 37.1 and a positive
PR: 98 outlook for the
RR: 20 future.
3. Encourage low 3. Early ambulation
levels of activity; decreases
to stand up, postpartum
walking up and hemorrhage and Long Term Evaluation:
Long Term Goal:
down the hall, if risk of After 2 hours, the
After 2 hours of nursing
capable– picking development of nursing interventions
interventions, the patient
up infant to deep vein were:
will be able to achieve the
promote thrombosis. Met
following long-term goals:
attachment. Partially met.
The patient will be able to Unmet
ambulate freely without the
4. Demonstrate 4. Deep breathing
presence of pain and As evidenced by:
deep breathing exercise helps to
discomfort.
exercises and promote healing of
The patient was able to
encourage surgical wounds.
ambulate without pain
patient to
 perform and discomfort.
exercises every 4
hours with 5-10
breaths during
exercise.

5. Instruct patient 5. This is to reduce

to use pain especially
supportive when moving.
materials such as
binders.

6. Teach the 6. This prevents

patient to infection or
perform hand introduction of
hygiene when microorganisms to
cleaning wounds the wound site.
and to keep the
C section wound
dry and clean
and maintain
frequent changes
of soiled peri
pad.
 Dependent: Dependent:

1. Administer 1. This will help

analgesic as decrease pain
prescribed by intensity.
the physician.

Interdependent/ Interdependent/Collabora
Collaborative: tive:

1. Collaborate with This includes neurological

medical and psychological factions
providers in as appropriate when pain
pain assessment. persists.

Student’s Name: Charisse Jasmine S. Dela Cruz Yr&Sec/Group No. BSN 2A- GROUP 3