De Castro, Janine Joy H.

March 08, 2010

BSN 112/ Group 46 Dr. Elizabeth Delos Santos

NURSING CARE PLAN

Px: Rechelle Rivera Age: 18

Nursing Diagnosis Goals and Objectives Nursing Intervention Rationale Evaluation

Acute pain related to Goal:

surgical incision due After 1 hour of Nursing
to cesarean birth Interventions the
patient will be able to
Subjective: alleviate pain.

 “ Masakit yung Objectives:

tahi ko sobra.”
 “Di ako 1. After 5 minutes  Provide Comfort  To alleviate pain The client was able to
makagalaw ng of discussion, Measures such by promoting enumerate ways on how
maayos dahil sa the client will be as repositioning non- to alleviate pain.
tahi ko, bawat able to or quiet pharmacological
galaw ko enumerate ways environment. pain
kumikirot on how to management.
siya.” alleviate pain.  Instruct patient  To reduce pain
 Madalas akong to us supportive especially when
irritable, hindi materials such moving
ko alam kung as binder
bakit, siguro
dahil sa tahi 2. After 10 minutes  Encourage early  Relaxes The client was able to
ko.” of discussion, ambulation, use muscles, and share different kinds of
the client will be of rocking chair, redirects exercises to promote
able to share wellness.
 different kinds or left side-lying attention away
Objective: of exercises to position as from painful
promote appropriate. sensation.
 Facial Grimace wellness.
with pain scale
of 8 (10 is the 3. After 10 minutes The client was able to
highest) of  Encourage  Deep breathing performed deep
 Protective demonstration, patient to do enhances breathing exercise.
gesture to avoid the client will be Deep Breathing respiratory
pain incision able to perform Exercise by effort. It
site deep breathing demonstrating promotes
 Expressive exercise. how to do healing of
behavior such it(every 4 hour surgical wounds.
as sighing and daily with 5-10
breaths during
moaning.
exercise.
 Teary eye
 Limited 4. After 5 minutes The client was able to
of discussion,  Instruct the know the different
movement  To distract
the client will be patient to use activities on how to
 Irritated and attention and
able to know the relaxation divert her attention to
sensitive to reduce tension.
different techniques and lessen pain.
touch encourage
activities on
how to divert diversional
her attention to activity such as
lessen pain. listening to
music, watching
television and
socialization
with others.