ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Impaired comfort Long Term Goal: Independent: Independent: Long Term Goal:
related to
“Masakit yung tiyan After 5 days of - Encourage diversional - Diverts the attention GOAL ACHIEVED
postpartum
ko” as verbalized by nursing activities such as from painful stimulant
the patient abdominal pain as interventions, the listening to music or After 5 days of nursing
evidenced by facial client will be able watching interventions, the
grimace, abdominal to experience - Provide adequate rest - To prevent fatigue that client was able to
guarding, and gradual reduction/ periods can impair ability to experience gradual
relief of pain manage or cope with reduction/ relief of
verbalization of
Objective: pain pain
feeling discomfort
RR: 18 - Measure abdominal
Short Term Goal: girth and fundal height - to establish baseline
PR: 85 data regarding the Short Term Goal:
In 8 hours, the contraction of the
BP: 120/80 client will be able GOAL ACHIEVED
- Avoid additional uterus
T: 36.8 to tolerate pain felt In 8 hours, the client
stressors or sources of
as evidenced by no discomfort whenever was able to tolerate
- Facial mask facial grimace and - To minimize the cause
of pain possible pain felt as evidenced
the client will also of exaggeration of the by no facial grimace
- Abdominal
guarding verbalize a patient and the client also
- 5/10 pain decrease in pain verbalized a decrease
felt from 5/10 to Collaborative: Collaborative:
felt in pain felt from 5/10
3/10 - Administer pain - To alleviate pain to 3/10
medications as
prescribed by the
physician
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Excess Fluid Long Term Goal: Independent: Independent: Long Term Goal:
volume related
“Maga yung binti at mga After 5 days of - Encourage high - Staying hydrated can help lose GOAL ACHIEVED
to compromised
paa ko” as verbalized by nursing intake of fluid some of the excess fluid more
the patient regulatory interventions, the - Avoid salty and quickly After 5 days of
mechanism as client will be able processed foods - Salty and processed foods nursing
evidenced by to experience - Position the result in fluid retention interventions, the
presence of gradual reduction client in a sitting - Standing up for too long directs client was able to
of edema on both position and the fluid toward feet and can experience gradual
edema in lower
reduction of edema
extremities. legs and feet elevate the feet lead to swelling. Elevating the
above the level feet above level of heart while on both legs and feet
of the client’s sitting lets the fluid flow more
Objective: Short Term Goal: heart and avoid evenly throughout the body
standing up for - To reduce extra pressure on the Short Term Goal:
- Presence of After 8 hours of too long client’s lower extremities and to
edema on nursing GOAL ACHIEVED
- Promote promote comfort
client’s lower interventions, the comfortable After 8 hours of
extremities client will be able loose clothes nursing
- Grading edema to reduce edema interventions, the
Collaborative: Collaborative:
of 2+ disappears on both legs and client was able to
within 10 secs. feet from a grading - To include the family to reduce edema on
- Educate the
of 2+ that family of the participate in therapeutic both legs and feet
disappears within client about the regimen from a grading of 2+
10 secs to a importance of that disappears
grading of 1+ that water within 10 secs to a
disappears within 5 grading of 1+ that
secs. disappears within 5
secs.
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Self-care deficit Long Term Goal: Independent: Independent: Long Term Goal:
related to
“Hindi ako masyado After 5 days of - Provide adequate - To reduce fatigue GOAL ACHIEVED
decreased
makagalaw ng maayos nursing rest periods and improve
kasi kakapanganak ko strength and interventions, the - Allow mother to vent strength After 5 days of nursing
lang” as verbalized by endurance as client will be able to out her feelings - To lessen her interventions, the client
evidence by perform personal - Provide information emotional stress was able to perform
the patient
verbalization of hygiene within level about self-care, - To prevent personal hygiene within
of own ability. including perineal infection level of own ability.
inability to
perform desired care, and hygiene - To promote good
activities of daily - Provide hygiene care hygiene
to patient such as - To ensure easier Short Term Goal:
living. Short Term Goal:
wound care dressing and
Objective: After 8 hours of GOAL PARTIALLY ACHIEVED
- Encourage use of comfort
- Appropriately nursing clothing one size After 8 hours of nursing
dressed interventions, the larger interventions, the client
- Tangled hair client will be able to was able to do self-care
Collaborative:
- Body weakness do self-care activities activities such as perineal
such as perineal care Collaborative: - To include the care and brushing her hair
and brushing her hair - Educate the family/ patient’s with minimal supervision
without someone significant other relative/ or assistance.
prompting or telling about how to do significant other
her to do so. wound care if the to participate in
patient becomes the regimen.
tired or not capable
of carrying out the
task
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Risk for Long Term Goal: Independent: Independent: Long Term Goal:
Infection
“Kagabi lang ako After 4 days of - Assess signs and - Fever may indicate GOAL ACHIEVED
related to
naoperahan” as nursing symptoms of infections infection
verbalized by the postoperative interventions, the especially temperature - to establish baseline After 4 days of nursing
patient wound client will be free - Measure abdominal data regarding the interventions, the client
from any signs and girth and fundal height contraction of the was free from any signs
symptoms of related - Emphasize the uterus and symptoms of related to
to infection importance of - It serves as a first infection
Objective:
handwashing technique line of defense
- Low vertical - Maintain aseptic against infection
cesarean technique when - Regular wound
section changing dressing/ dressing promotes
- Clean and intact Short Term Goal: Short Term Goal:
caring wound fast healing and
abdominal - Keep area around the drying of wounds GOAL ACHIEVED
dressing After 5 hours of
wound clean and dry - Wet area can be
- Fundic height: nursing After 5 hours of nursing
lodge area of
interventions, the interventions, the client
24 cm bacteria
- T: 36.8 C client will be free was free from any signs
from any signs and Collaborative: Collaborative: and symptoms of infections
symptoms of as manifested by absence
- Administer antibiotic as - Antibiotics will help
infections as of fever.
ordered by the Doctor. kill and stop the
manifested by
absence of fever. proliferation and
growth of the
bacteria which could
cause infection.
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Readiness for Long Term Goal: Independent: Independent: Long Term Goal:
enhanced
“Napadede ko After 4 days of nursing - Assess mother’s - To establish baseline and GOAL ACHIEVED
breastfeeding
naman yung anak interventions, the client knowledge and direction for
ko pagkanganak will be able to promote previous experience teaching/planning After 4 days of nursing
ko” as verbalized effective breastfeeding with breastfeeding - To promote effective interventions, the client
behaviors such as good - Demonstrate how to breastfeeding techniques was able to promote
by the patient
attachment and suckling support and position - This provides practice and effective breastfeeding
the infant the opportunity to correct behaviors such as good
- Observe mother’s misunderstanding and add attachment and suckling

Short Term Goal: return demonstration additional information to

of breastfeeding
After 6 hours of nursing - Encourage the mother
Objective: interventions, the client to follow a well-
will be able to
- Breast balanced diet
everted demonstrate effective containing an extra 500
and techniques for calories/day and drink
lactating. breastfeeding such as at least 2,00 t 3,000 mL
proper positioning for fluid/day.
breastfeeding.
Collaborative:
- Educate the father or
significant other about
the benefits of
breastfeeding how to
manage common
lactation challenges.
promote the optimal
experience for breastfeeding. Short Term Goal:
- There is an increased need
GOAL ACHIEVED
for maternal energy as well
as increased fluid intake After 6 hours of nursing
during lactation interventions, the client
was able to demonstrate
Collaborative:
effective techniques for
- Enlisting the support of breastfeeding such as
father/ significant other is proper positioning for
associated with a higher ratio breastfeeding.
of successful breastfeeding at
6 months and to include
them to participate in
therapeutic regimen