Nursing Process/Care Plan
Nursing 122
Students Name_ ________ Initials of Client______________ Dates of Care_________________
Nursing Design (Orem) __ Supportive-Educative_____________________________
Nursing Diagnosis
Outcomes
Pain R/T disruption of skin,
tissue, and muscle integrity
secondary to Cesarean section as
evidenced by patient stating a
pain level of 6 out of 10.
Short-Term Goal:
Patient will verbalize decrease 2) Monitor client’s vital
intensity of pain from 6/10 to
3/10 after 1-2 hours of nursing
intervention.
Long-Term Goal:
The patient will have no further
complaints of pain after 8 hours
of nursing interventions.
Plan of Care Rationale (Scientific) Evaluation: Compare
expected to actual outcomes
1) Assess the nature of the 1) Pain is a subjective experience. The women’s
pain, including location, perception of pain must be understood to plan the
characteristics, onset, most effective, yet least intrusive, pain-relief
duration, frequency, and measures. (Green, pg.19) Short-Term Goal:
precipitation factors; 2) The fifth sign is pain, and it should be assessed
use a numbered scale to frequently to determine the woman’s comfort and the Goal met. Patient verbalized
rate severity. need for continued analgesia and to adjust nursing pain level decreasing from 6
actions for ongoing comfort. Blood pressure, pulse, to 3 after 1 hour of nursing
respiration, and alertness are important indicators of intervention including
signs including: blood both pain level (eg., elevated BP, tachycardia, administering of pain med.
pressure, respiratory increased respirations, or restlessness) and too much
rate, pulse rate and analgesia (eg., bradycardia, hypotension, and
temperature every hour respiratory depression). (Green, pg. 19)
until pain is relieved. 3) When an individual’s basic human needs are met,
pain may be reduced. Internal endorphins affect Long-Term Goal:
3) Encourage perception of pain, which also is influenced by
verbalization of feelings psychosocial factors such as the woman’s Unable to assess. Patient’s
and concerns. expectations, childbirth education, and her pain level should be
interpretation of what is occurring throughout the continuously assessed until
4) Assess for any effects birthing experience. (Green, pg. 19) discharge.
the women’s culture 4) A pain response (such as crying out) may be
and religion may be acceptable in some cultures but not in others; the
having on her nurse must be careful not to confuse stoic acceptance
perception of pain and with absence of pain. Some religions view pain as a
her pain response. blessing, while others see it as punishment. This will
affect the woman’s perception of and anxiety about
the pain. (Green, pg. 20)
5) Educate patient the use 5) Based on the gate-control theory, noninvasive pain
 Nursing Process/Care Plan
Nursing 122

of non-pharmacologic relief techniques help reduce the perception of pain

techniques such as deep
breathing technique,
simple relaxation
therapy, guided
imagery. 6)
6) Provide optimal pain
relief with doctor’s
prescribed analgesics.
by stimulating large-diameter nerve fibers that carry
information such as touch to inhibit pain
transmission (analogous to closing the gate). (Green,
pg. 20)
The pharmacologic method of pain relief used is
dependent on the woman’s special needs and desires,
and the benefits versus risks to the woman and baby.
The nurse can assist the family in making an
informed decision by describing the agents being
considered, evaluation the mother’s willingness to
participate in pain-relief measures, and assessing the
ability of the significant others to provide support.
(Green, pg. 20)

Citation:
1. Green, C. J. (2016). Maternal newborn nursing care plans. Burlington, MA: Jones & Bartlett Learning.