Você está na página 1de 5

II. NURSING CARE PLAN No.

1
Assessment
Nursing
Diagnosis
Planning Intervention Rationale Evaluation
Subjective:
Masakit yung
tahi ko ,as
verbalized
by the client.
Pain scale: 7/10


Objective:
Facial Grimace
Guarding
behaviour

PR=71 bmp

TEMPERATURE
= 37.1 C


RR= 18cpm

BP= 110/70 mmHg
Acute pain related
to tissue injury
secondary to
surgical
incision;Caesarian
Section.
Short term goal:
After 30 minutes of
nursing
intervention, the
client will be
able to verbalize
alleviation of
pain, from a pain
scale of 7/10 to
6/10.

Long term goal:
Within 8 hours, the
client will be
able to report
that pain is
relieved/controll
ed

Within 8 hours, the
client will be
able to follow
prescribed
pharmacological
regimen.


Independent
Encourage use of
relaxation
techniques such
as listening to
music.




Encourage
verbalization of
feelings about
the pain.

Encourage
adequate rest
period.

Instruct deep
breathing
exercise.






Increases release
of endorphins and enhance the
therapeutic effects of pain
management





To serve as baseline data.




To prevent fatigue.



to relieve pain.







Short term goal:
After 30 minutes of
nursing intervention,
the client will be able
to verbalize
alleviation of pain,
from a pain scale of
7/10 to 6/10.

GOAL MET

Long term goal:

Within 8 hours, the
client will be able:

to report the pain is
relieved

will be able to
follow prescribed
pharmacological
regimen.


demonstrate ways
on how to manage
























Within 8 hours, the
client will be
able to
demonstrate
ways on how to
manage pain.


Dependent
Take medicines as
prescribed

To alleviate the pain that the
client is experiencing.
pain.

GOAL MET
NURSING CARE PLAN No. 2
Assessment
Nursing
Diagnosis
Planning Intervention Rationale Evaluation
Subjective:
none

Objective:
dressing dry and
intact
Risk for infection
related to
inadequate
primary
defense
secondary to
Short term goal:
After 30 minutes of
nursing intervention,
the client and
significant others
will be able to
identify causative
factors and signs and
symptoms of
infection and report
them to the health
care provider
accordingly.

Long term goal:
Within 8 hours, the
client will be able to
achieve timely
wound healing and
be free of signs of
infection and
inflammation,
purulent drainage
and fever.
Independent
Instruct proper
handwashing.


Inspet incision
site/dressing.


Note for
fever,chills,
diaphoresis, and
increasing
abdominal pain.





Dependent
Take medicines as
prescribed

Reduces risk of spread of
bacteria.


Provides early detection of
developing infectious process.


Suggestive of presence of
infection/developing sepsis,
abscess, peritonitis.








To alleviate the pain that the
client is experiencing.
Short term goal:
After 30 minutes
of nursing
intervention, the
client and
significant others
will be able to
identify causative
factors and signs
and symptoms of
infection and report
them to the health
care provider
accordingly.
GOAL MET

Long term goal:
Within 8 hours,
the client will be
able to achieve
timely wound
healing and be free
of signs of infection
and inflammation,
purulent drainage
and fever.
GOAL MET
NURSING CARE PLAN No. 3
Assessment
Nursing
Diagnosis
Planning Intervention Rationale Evaluation
Subjective:
Hindi pa ako
dumudumi
,as
verbalized
by the client.

Objective:
patient has not
yet defecated
normal
elimination pattern
has not yet returned
Risk to
constipation
related to post
pregnancy
cesarea section.
Short term goal:
After 30 minutes of
nursing
intervention, the
client will be
able to
demonstrate
behaviours or
plan of lifestyle
change to
prevent
developing
problems.



Long term goal:
Within 8 hours, the
client will be
able to have
normal
elimination
patter.
.


Independent
Assess client's normal
bowel pattern abot how many
times a day she defecates.





Encourage to increase fluid
intake







Encourage ambulation
within individual limits.








To provide baseline
information.






To soften stool and
facilitate passage
through the colon






To stimulate
contraction of
intestines and avoid
post operative
complication.





Long term goal:
After 30 minutes
of nursing
intervention, the
client will be able
to demonstrate
behaviours or plan
of lifestyle change
to prevent
developing
problems.
GOAL MET



Short term goal:
Within 8 hours,
the client will be
able to have normal
elimination patter.
GOAL MET