CUES (defining characteristics of Nrsg Dx) Subjective: “Masakit yung tahi ko lalo na kapag gumagalaw ako” Objective: >Facial Grimace

with pain scale of 4 >Protective Gesture to avoid pain in incision site >Expressive Behavior such as sighing >Limited movement

Nursing Diagnosis Problem & Etiology S/Sx) Acute pain related to surgical incision due to cesarean birth as evidenced by facial grimace with a pain scale of 4

Background Knowledge (pathophysiologic/psychosocial Explanation/consequences of Nrsg. Dx) Pain Stimulus→visceral and Cutaneous Fibers:Nociceptor(skin and internal organ)→Dorsal Horn→reticular Formation(sleep center)→Thalumus→Limbic Cortex→Cerebral Cortex→Perception of Noxious stimuli The harmful effects of unrelieved acute pain can affect the pulmonary, carrdiovascular,GIT,Endocrine system and can cause severe pain and it may increase the risk of developing physiologic disorders.

Goals and Objectives

Nursing Interventions

Rationale

Evaluation

After 2 hours of Nursing Interventions the patient’s pain scale will decrease from 4 to 2

>Provide Comfort Measures such as repositioning or quiet environment >Instruct the patient to use relaxation techniques and encourage diversional activity such as listening to music,watching television and socialization with others >Instruct patient to us supportive materials such

>To alleviate pain by promoting nonpharmacological pain management >To distract attention and reduce tension

After 2 hours of Nursing Interventions the patient’s pain scale decreased from 4 to 2 Goal is met

>To reduce pain especially when moving

as binder >Encourage patient to do Deep Breathing Exercise by demonstrating how to do it(every 4 hour daily with 5-10 breaths during exercise >It promotes healing of surgical wounds