NURSING CARE PLANProblem: Abdominal Pain secondary to Caesarian Section Nursing Diagnosis: Altered comfort-acute pain related to surgical

incisions. Taxonomy: COGNITIVE-PERCEPTUAL PATTERN Cause Analysis : CUESOBJECTIVESNURSING INTERVENTIONRATIONALESubjective: Gasakit pa jud kayo akong tiyankay bag-o lang ko nanganak Objective: >Facial grimace>General Weakness>Restlessness STO: After 2-4 hours of giving nursinginterventions, the patients paindecreases on a p ain scale of 1-10with pain less than 2, as evidence of the absence of facial gri mace andfeeling of relaxation. LTO: After 8 hours of giving effectivenursing intervention, the patientslevel of pain is 0 and is able to sleepor rest appropriately. Independent: Reassure patient that youknow pain is real and willassist her in dealing with it . Assess and record pain and itscharacteristics, location,quality, frequency anddu ration. Encourage relaxation exercisesuch as deep breathingexercise when pain occurs. Review factors that aggravateor alleviate pain. Provide comfort measures anddiversional activities andpromote bed rest, allowing the patient to assume of comfort. Dependent: Prove and implementprescribe dietary medications. Administer medications if indicated. e.g., Analgesics Fear that pain will not beaccepted as real increasestensions, anxiety anddecreas es pain tolerance. Data assist in evaluating painand pain relief and identifyingmultiple sources an d types of pain. Promotes relaxation,refocuses attention, and mayenhance coping abilities. Helpful in establishingdiagnosis and treatmentneeds. This contributes pain, relief muscle tension and anxietywhenever patient natura llyassume least painful position. Patient may receive nothingby mouth (NPO) initially.When oral intake is allowed, food choices depend of thediagnosis. Analgesics are more effective if administered early in paincycle.

NURSING CARE PLAN Problem Identified: bilateral flank pain Nursing Diagnosis: Acute Pain r/t biological injuring agent: inflammatory process secondary to Urin ary Tract Infection Taxonomy: Cognitive-Perceptual Pattern Cause Analysis: Fluid shifts from the intravascular to the interstitial spaces as a result of th e release of vasoactive amines by inflammatory process. It causes the nerve endi ngs to becompress hence resulting in excruciating pain. Reference: Medical Surgical Nursing 10 th Edition Volume 2 by Smeltzer and Bare CUESOBJECTIVESNURSING INTERVENTIONRATIONALE Subjective: Sakit gyud akoang mga kiliran diri saluyo as verbalized by PtP pain upon movementQ sharp sensationR bilateral flank S 3/10-4/10T pain lasts for a maximum of 20-40 seconds Objective: facial grimace Weakness Short term objectives: Within 8 hours of interventions, the pt.will be able to verbalize a relief or co ntrolfrom pain. Long term objectives: Within 3 days of giving effective nursinginterventions, the patient will be able toverbalize relief of pain and to demonstrateuse of relaxation skills and diver sionalactivities as indicated for individualsituation. Independent Observe and document location, severity(010 scale), and character of pain (e.g.,s teady, intermittent, colicky). Note response to medication, and report to physic ian if pain is not being relieved.Promote bedrest especially in low-fowlers posit ionAllow patient to assume position of comfort.Control environmental temperature .Encourage use of relaxation techniques,e.g., guided imagery, visualization, dee p- breathing exercises. Provide diversionalactivities.Make time to listen to and maintainfrequent contact with patient. Independent Assists in differentiating cause of pain, and provides information about disease progression/resolution, development of complications, and effectiveness of inte rventions.Severe pain not relieved by routinemeasures may indicate developingcom plications/need for further intervention.Bedrest in low-Fowlers position reducesi ntra-abdominal pressure;Patient will naturally assume least painful position.Coo l surroundings aid in minimizingdermal discomfort.Promotes rest, redirects atten tion, mayenhance coping.Helpful in alleviating anxiety andrefocusing attention, which can relieve Collaborative Administer Mefenamic Acid 250 mg poq8h, prn for pain pain. Collaborative Management of mild to moderate pain Reference: Nursing Care Plans 6 th Ed. by Doenges NURSING CARE PLAN PROBLEM: Anxiety NURSING DIAGNOSIS: Anxiety related to illness secondary to hype

rtensionTAXONOMY: Self Perception Concept PatternCAUSE ANALYSIS: Anxiety is comm on reaction to stress, a state of mental uneasiness, apprehension, or feeling of helplessness related to impending or unidentified threat to self or significant relationship. CUESOBJECTIVESNURSING INTERVENTIONRATIONALEEXPECTED OUTCOME SUBJECTIVE:Sige ko ug hunahuna saakong kahimtang karonverbalized by the patient.OB JECTIVE:>Fear of unspecificconsequences.>restless>the patient appear tensed& anx iousSTO:After 8 hours of givingnursing interventions the patient will be able to lessen or decrease as evidenced byexpressing feelings regardingthe situation. L TO:After 3 days of giving nursingintervention the patient will beable to verbali zed awareness of feeling and healthy ways todeal with them and demonstratedecrea sing level of anxiety.INDEPENDENT:>Assure patient of confidentiality within limi ts of situation.>Maintain frequent contact with patient, talk with and touch pat ient.>Provide reliable and consistentinformation and support for S.O.>Encourage in guided imagery/relaxation techniques such asdeep breathing and socializingwit h S.O.DEPENDENT:>Administer antianxietymedication as needed.>provides reassuranc e andopportunity for patient to problem solve solutions toanticipated situations .>Provide assurance that patient is not alone or rejected: conveys respectfor an d acceptance of the person, fostering trust.>Allow for better interpersonal inte raction andreduction of anxiety andfear.>Moderate anxietyheightens awareness and can help motivate patient tofocus on dealing with problems.>May be useful for br ief After 8 hours of giving nursinginterventions the patient wasable to lessen o r decrease asevidenced by expressingfeelings regarding the situation.After 3 day s of giving nursingintervention the patient wasable to verbalized awareness of f eeling and healthy ways todeal with them and demonstratedecreasing level of anxi ety.