NAME: OYARDO CHERILYN BED NO.

: 408
ATTENDING PHYSICIAN: DR.BALDOVINO DIET: DIET AS TOLERATED
DIAGNOSIS: POST-PARTUM
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE: Acute vaginal pain After the 8 hours span of  Provide rapport  To gain trust and full GOAL:
“sumasakit yung tahi related to right medio my care the patient will be with the patient. cooperation during PARTIALLY MET
paminsanminsan” as lateral episiotomy as able to express alleviation the pain alleviation After the 8 hours span of care
vervalized. evidence by facial of pain from pain scale of procedures. the patient able to express
grimacing, guarding 6 to 2.  Monitor vital signs.  Vital signs altered alleviation of pain from pain
OBJECTIVE: behavior. A. Will be able to during acute pain. scale of 6 to 3.
 Facial know different A. GOAL MET
grimace. techniques in  Provide a  To aid in alleviation of Able to know
 Pain scale of alleviation of therapeutic pain. different techniques
6. pain. environment. in alleviation of pain.
 Slowed B. Will comfortably  Encourage  To assist in B. GOAL MET
movement. fall asleep. verbalization of evaluation. At the end of the
feelings. shift the patient able
 Encourage to do to sleep comfortably.
diversional  To alleviate pain.
activities.
 Encourage rest and
sleep  To assess in
alleviation of pain.
NAME: CULAWAY, IRENE BED NO.: P2
ATTENDING PHYSICIAN: DR.BALDOVINO DIET: DIET AS TOLERATED
DIAGNOSIS: POST-PARTUM
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE: Acute pain related to After the 8 hours span of  Establish rapport  To gain trust and GOAL: MET
“may lumalabas pa childbirth pain my care the patient will be with the patient. cooperation. After the 8 hours span of my
pong dugo at minsan characterized by facial able to express decreased  Establish NPI.  To assess the patient. care the patient express that
sumasakit” as mask of pain and felt pain from pain scale of  Monitor vital signs.  Vital signs altered the felt pain decrease to pain
verbalized. diaphoresis. 4 to 1. during acute pain. scale of 1.
OBJECTIVE: A. Will be able to  Provide safety  To avoid further A. Knew and able to
 Diaphoresis know and execute environment. injuries. execute pain
 Facial mask of pain alleviation  Encourage  To assess the alleviation
pain. techniques. verbalization of condition of the techniques.
 Pain scale of 4 feelings. patient.
 Encourage do  To alleviate pain.
diversional activities.
NAME: DEMETRIAL, VILMA BED NO.: P2
ATTENDING PHYSICIAN: DR.ETORMA DIET: DIET AS TOLERATED
DIAGNOSIS: POST-CS
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE: Acute abdominal pain After the 8 hours span of  Provide rapport with the  To gain full trust and GOAL: MET
“masakit parin ang tahi related to post-CS my care the patient will be patient. cooperation while After the 8 hours span of care
implementing pain
sa akin” as verbalized injury as manifested by able to deal with the post- alleviation procedures. the patient able to deal with
OBJECTIVE: guarding behavior. operative pain.  Monitor vital signs.  To assess abnormalities the post-operative pain.
 Guarding A. Will be able to and evaluation of Verbalized “nawa-wala wala
behavior know how to conditions. na ang sakit”
 Provide hazard free  To reduce further risk of
 Slowed alleviate pain. A. GOAL MET
environment such as injuries.
ambulation. B. Will be able to scattered things in the Able to know how to
 Diaphoresis. mobilize much floor. alleviate the pain by
better with safety.  Encourage verbalization  To assess the condition of practicing the
of feelings. the patient. implemented
 Encourage to do  To alleviate pain.
activities.
diversional activities.
 Advice to ambulate.  To aid in peristaltic
movement and B. GOAL MET
elimination. Able to mobilize
 Instruct in use of  To assist client explore more frequently and
relaxation exercises such methods for alleviation of walks more often.
as focused breathing. pain.
NAME: AGNO, MILDREDA BED NO.: 410
ATTENDING PHYSICIAN: DR.ETORMA DIET: CLEAR LIQUID DIET
DIAGNOSIS: POST-CS (1)
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE: Acute post-operative After the span of my 8  Establish rapport  To gain full trust and GOAL: MET
“masakit yung opera” pain related to post- hours care the patient will cooperation while doing After the 8 hours span of care
with the patient.
the procedure.
as verbalized. cesarean injury as be able to ambulate  Monitor vital signs. the patient able to ambulate.
 To aid in assessment
OBJECTIVE: evidence by guarding easily. A. GOAL:
and evaluation of
 Slow behavior, facial grimace A. Will verbalized the PARTIALLY MET
patient’s condition.
movement and slowed movement. decreased felt  Establish NPI.  To facilitate data
Verbalized decreased
 Guarding pain from pain gathering. felt pain from 5 to 3
behavior scale of 5 to 2.  Encourage  To facilitate assessment of pain scale.
 Facial B. Will know how to verbalization of patients condition and B. GOAL: MET
execute methods effectiveness of the Knew and executed
grimace feelings. implemented procedures.
of alleviating pain.  Encourage  To alleviate pain.
the pain alleviation
diversional activities. methods.
 Advice to ambulate.  To aid in peristaltic
movement and
 Encourage relaxation elimination.
and sleep.  To facilitate faster
recovery and
alleviation of pain.
NAME: NEGROSA, EMELOU BED NO.: 417
ATTENDING PHYSICIAN: DR.ETORMA DIET: DIET AS TOLERATED
DIAGNOSIS: POST-CS (6)
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE: Acute post-operative After the span of my 8  Establish rapport  To gain full trust and GOAL: MET
“masakit ng di gaano pain related to post- hours care the patient will cooperation while doing After the 8 hours span of care
with the patient.
the procedure.
ang tahi” as cesarean injury as be able to ambulate  Monitor vital signs. the patient able to ambulate.
 To aid in assessment
verbalized. evidence by guarding easily. A. GOAL:
and evaluation of
OBJECTIVE: behavior, facial grimace A. Will verbalized the PARTIALLY MET
patient’s condition.
 Slow and slowed movement. decreased felt  Establish NPI.  To facilitate data
Verbalized decreased
movement pain from pain gathering. felt pain from 5 to 3
 Guarding scale of 3 to 0.  Encourage  To facilitate assessment of pain scale.
behavior B. Will practice verbalization of patients condition and B. GOAL: PARTIALLY
effectiveness of the
 Facial methods of feelings. MET
implemented procedures.
grimace alleviating pain.  Encourage  To alleviate pain.
Often practice the
 Pain scale of diversional activities. pain alleviation
3  Advice to ambulate.  To aid in peristaltic
methods.
movement and
 Encourage relaxation elimination.
and sleep.  To facilitate faster
recovery and
alleviation of pain.
NAME: EDRIGA, SWEET GRASHELA BED NO.: 416
ATTENDING PHYSICIAN: DR.ETORMA DIET: SOFT
DIAGNOSIS: POST-CS + BTL (2)
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE: Acute post-operative After the span of my 8  Establish rapport  To gain full trust and GOAL: MET
“masakit yung opera pain related to post- hours care the patient will cooperation while doing After the 8 hours span of care
with the patient.
the procedure.
kapag gumagalaw” cesarean injury as be able to ambulate  Monitor vital signs. the patient able to ambulate.
 To aid in assessment
as verbalized. evidence by guarding easily. A. GOAL:MET
and evaluation of
OBJECTIVE: behavior, facial grimace A. Will verbalized the Verbalized decreased
patient’s condition.
 Slow and slowed movement. decreased felt  Establish NPI.  To facilitate data
felt pain from 6 to 2
movement pain from pain gathering. pain scale.
 Guarding scale of 6 to 2.  Encourage  To facilitate assessment of B. GOAL: MET
behavior B. Will know how to verbalization of patients condition and Knew and executed
effectiveness of the
 Facial execute methods feelings. the pain alleviation
implemented procedures.
grimace of alleviating pain.  Encourage  To alleviate pain.
methods.
diversional activities.
 Advice to ambulate.  To aid in peristaltic
movement and
elimination.
 Encourage relaxation  To facilitate faster
and sleep. recovery and
alleviation of pain.
NAME: EDRIGA, SWEET GRASHELLA BED NO.: 416
ATTENDING PHYSICIAN: DR.ETORMA DIET: DIET AS TOLERATED
DIAGNOSIS: POST-CS + BTL (3)
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE: “inuobo Ineffective airway After the span of my 8  Provide rapport with  To gain trust and GOAL: MET
ako pero hindi naman clearance related to hours care the patient will the client. cooperation. After the 8 hours span of care
lumalabas” as retained secretions as be able to mobilize  Encourage deep-  To mobilize the patient able to mobilize
verbalized. manifested by ineffective secretion. breathing and secretion. secretion.
OBJECTIVE: cough. A. Will know how to coughing exercise. A. GOAL MET
 Ineffective execute methods  Position head midline  To open or maintain Execute methods of
cough of mobilizing with flexion patent airway. mobilizing secretions.
 restless secretions. appropriate for
condition
 Keep environment  To maintain airway.
allergen free
according to
individual situation.
 Increase fluid intake.  To help liquefy
secretions.