ASSESSMENT NURSING GOALS AND INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES
Subjective: Acute pain related GOAL:  Establish  To easily gain
“ Kasakit sang to abdominal At the end of my Rapport to cooperation
tinahian ko, nd ko incision due to nursing intervention the patient. form the
mayo ka giho” caesarean surgery. of 8 hours of duty, the patient.
“ Everytime magiho patient will be able to  Monitor Vital  To have
ko kasakit sang report pain is relieved Signs baseline data
tinahian ko especially or controlled. and for
mag bangon ko.” OBJECTIVES: comparison for
After 2 hours of future data.
Obejctive: nursing intervention,  To enhance
 Temperature: the client will:  Perform patient’s self-
37.4  Report pain bedside care esteem and to
 PR: 88 bpm intensity from provide
 RR: 20 cpm 7 to 8 will comfort to the
 Bp: 130/90 decrease at 4 patient
 Rated pain as to 5 from 0 to  By getting the
7 to 8 out of 10 pain scale.  Observe and following
0 to 10  Participate in document information,
 Pain demonstrating location, we are
increases techniques to severity and assisting in
when patient relieve pain. character of differentiating
moves  Have ability to pain. cause of pain
vigorously manage the and providing
 Facial situation. information
Grimace about disease
 Pallor progression/
 Wound: Dry, resolution,
no discharges development
noted. of
 Dressing and complication
plaster were and effective
clean and intervention.
 fully covered  Bedrest in low
the incision fowler’s
site.  Promote position
 No foul odor bedrest, reduces
noted on the allowing intraabdominal
site. patient to pressure.
assume
position of
comfort.
 Control  Cool
environment surrounding
temperature aids in
minimizing
dermal
discomfort.
 Administer  Nubain is
nubain as indicated to
ordered by relief of
physician moderate to
severe pain.