ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
Sobrang sakit nitong
tahi ko. as verbalized
by the patient.

Objective:
>Pain scale of 8/10
>Teary eyed
>(+) guarding
behavior
>(+) facial grimace
>Irritable
>Pale palpebral
conjunctiva
>Skin warm to touch

V/S taken as follows:
T=
PR=
RR=
BP
Acute pain related to
disruption of skin and
tissue secondary to
cesarean section.
After 4hrs. of nursing
intervention, patient
will verbalize
decrease intensity of
pain from 8/10 to
3/10.
Independent:
>Established rapport.


>Monitored vital
signs.
>Assessed quality,
characteristics,
severity of pain.



>Provided
comfortable
environment-
changed bed linens
and turned on the
electric fan.
>Instructed to put
pillow on the
abdomen when
coughing or moving.








>Instructed patient to
do deep breathing
and coughing

>To have a good
nurse-client
relationship.
>To establish a
baseline data.
> To establish a
baseline data for
comparison in making
evaluation and to
assess for possible
internal bleeding.
>Calm environment
helps to decrease the
anxiety of the patient
and promote
likelihood of
decreasing pain.
>To check for
diastasis recti and
protect the area of
the incision to
improve comfort. And
to initiate
nonstressful muscle-
setting techniques
and progress as
tolerated, based on
the degree of
separation.
>For pulmonary
ventilation, specially
when exercising, and
After 4hrs. of nursing
intervention, the
patient verbalized
pain decreased from
a scale of 8/10 to
3/10 as evidenced by
(-) facial grimace
(-) guarding behavior.
Frequent small talks
with significant
others.
GOAL MET.
exercise.

>Provided
diversionary
activities. Initiate
ankle pumping, active
lower extremity ROM
and walking.

Collaborative:
>Administer analgesic
as per doctors order.
to relieve stress and
promote relaxation.
>To promote
circulation, prevent
venous stasis,
prevent pressure on
the operative site.



>Relieves pain felt by
the patient.
Subjective:
>none

Objective:
>dressing dry and
intact

V/S taken as follows:
T=
PR=
RR=
BP=
Risk for infection
related to inadequate
primary defenses
secondary to surgical
incision.
STG:
After 4hrs. of nursing
intervention, patient
will be able to
understand causative
factors, identify signs
of infection and
report them to health
care provider
accordingly.

LTG:
After 2-3 days of
nursing intervention,
patient will achieve
timely wound
healing, be free of
purulent drainage or
erythema, be afebrile
and be free of
infection.
Independent:
>Monitor vital signs.

>Inspect dressing and
perform wound care.

>Monitor WBC.




>Monitor
temperature,
redness, swelling,
increased pain, or
purulent drainage at
incisions.
>Wash hands and
teach other
caregivers to wash
hands before contact
with patient between

>To establish a
baseline data.
>Moist from drainage
can be a source of
infection.
>Rising WBC indicates
bodys efforts to
combat pathogens;
normal values: 4000-
11,000 mm
3

>These are signs of
infection.




>Friction and running
water effectively
remove
microorganisms from
hands. Washing
Patient is expected to
be free of infection,
as evidenced by
normal vital signs and
absence of purulent
drainage from
wounds, incisions,
and tubes.
procedures with
patient.




>Encourage fluid
intake of 2000ml to
3000ml per day.





>Encourage coughing
and deep breathing:
consider use of
incentive spirometer.





Collaborative:
>Administer
antibiotics as per
doctors order.
between procedures
reduces the risk of
transmitting
pathogens from one
area of the body to
another.
>Fluids promote
diluted urine and
frequent emptying of
bladder; reducing
stasis of urine, in
turn, reduces risk of
bladder infection or
UTI.
>These measures
reduce stasis of
secretions in the
lungs and bronchial
tree. When stasis
occurs, pathogens
can cause upper
respiratory infections,
including pneumonia.

>Antibiotics have
bactericidal effect
that combats
pathogens.
Objective Cues:
>Patient has not yet
eliminated since
delivery.
>Absence of bruit
sounds.
Risk for constipation
related to post
pregnancy secondary
to cesarean section.
STG:
Within 4hrs. of
nursing intervention,
the patient will be
able to demonstrate
behaviors or lifestyle
Independent:
>Ascertain normal
bowel functioning of
the patient, about
how many times a
day she defecate.

>This is to determine
the normal bowel
pattern.


After 4hrs. of nursing
interventions, the
patient was able to
identify measures to
prevent infection as
manifested by clients
>Normal pattern of
bowel has not yet
returned
changes to prevent
developing problem.

LTG:
Within 3 days of
nursing interventions,
the patient will be
able to maintain
usual pattern of
bowel functioning.
>Encourage intake of
foods rich in fiber
such as fruits.

>Promote adequate
fluid intake. Suggest
drinking of warm
fluids, especially in
the morning to
stimulate peristalsis.
>Encourage
stimulation such as
walking within
individual limits.


>However, since she
has had cesarean,
also encourage
adequate rest
periods.

Collaborative:
>Administer bulk-
forming agents or
stool softeners such
as laxatives as
indicated or
prescribed by the
physician.
>To increase the bulk
of the stool and
facilitate the passage
through the colon.
>To promote moist
soft stool.




>To stimulate
contractions of the
intestines and
prevent post
operative
complications.
>To avoid stress on
the cesarean
incision/wound.




>To promote
defecation.
verbalization of:
Iinom ako ng
maraming tubig at
kakain ng prutas para
makadumi ako.