CORDOVA, Bethel Ann A.

Nursing Care Plan - Assignment

2nu01 – St Luke’s College of Nursing Clinical Duty – ARMMC – Maternity

ASSESSMENT NURSING PLANNING IMPLEMENTATION OUTCOME

DIAGNOSIS

SUBJECTIVE DATA: Acute Pain SHORT TERM GOAL: Established good rapport  Goal met. After
related to 2 hours of
“Masakit sobra yung tahi After 1-2 hrs. of nursing Rationale: To achieve a good
disruption of intervention, the
ko.” as stated by the intervention, the patient nurse-client relationship.
skin and tissue patient states
patient. can verbalize reduced of
secondary to that the pain
pain or discomfort from
cesarean section. Monitored Vital signs has reduced
7/10 to 3/10
from a scale of
OBJECTIVE DATA: Rationale: To establish a 7/10 turns 3/10
baseline data.
 Pain: 7/10 as evidenced
LONG TERM GOAL: by:
 The patient is on 4
hourly vital signs Absence of Pain (-) Facial
Assessed quality,
 Temp: 36.4 Grimace
characteristics, severity
 BP” 120/80 (-) Guarding
of pain
behavior. The
 PR: 82
Rationale: To have a standard patient is able
 RR: 24
data for correlation in making to have frequent
 (+) Facial grimace
assessment for possible internal talk with her
 Irritable bleeding. family.
 (+) Guarding
behavior
Instructed to support or
splint the abdominal
incision when moving,
coughing and deep
breathing.
Rationale: To protect the area
of the incision and to improve
comfort.
 Instructed patient to do
deep breathing and
coughing exercise
Rationale: For pulmonary
ventilation, to relieve stress and
promote relaxation.

Encouraged ambulation
Rationale: To promote
circulation, prevent venous
stasis, to prevent pressure on
the operative site.

Collaborative:
Administer analgesic as
per doctor’s order.

Rationale: Relieves pain felt by

the patient; Promotes comfort
by blocking pain impulses.