ASSESSMENT NURSING OBJETIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
S: Acute pain related After 1-3 hours of INDEPENDENT: The goal is met.
“sakit kayo akong to disruption of skin nursing intervention,  Established - To have a After 3 hours of
tahi miss.” As tissue secondary to patient will verbalize rapport. good nurse- nursing intervention,
verbalized by the secarean section. decrease intensity client the patient
patient of pain from 8/10 to relationship. verbalized pain
3/10.  Monitored vital - To establish decreased from a
O: signs. a baseline scale of 8/10 to 3/10
 Pain scale of data. as evidenced by:
8/10  Assessed - To establish  Decreased
 Teary eyed quality, baseline data facial grimace
 With guarding characteristics, for  Decreased
behaviour severity of comparison 0guarding
 Facial pain. in making  Have frequent
grimace evaluation small talks
 Irritable and to assess with
 Skin warm to for possible significant
touch internal others.
 Vital signs bleeding.
taken as  Provided - Calm
follows: comfortable environment
Temp= environment helps to
37.8°C and change decrease the
PR= 80bpm bed linens and anxiety of the
RR= 22cpm adjust the patient and
BP= 110/80 ventilation. promote
likelihood of
decreasing
pain.
 Instructed - To check for
patient to put diastitis recti
pillow on the and protect
abdomen the area of
when the incision to
coughing or improve
moving. comfort. And
to initiate non
 stressful
muscle-
setting
techniques
and progress
as tolerated,
based on the
degree of
separation.
 Provided - To promote
diversionary circulation,
activities. prevent
Initiate ankle venous
pumping, stasis,
active lower prevent
extremity pressure on
ROM, and the operative
walking. site.
COLLABORATIVE:
 Administer - Relieves pain
analgesic as felt by the
per doctor’s patient.
order.