NURSING
CUES/EVIDENCES
Subjective:
Verbalize “Wala jud koy idea
unsaon pag limpyo ang
samad”
“Mahadlok ko mo hikap kay
sakit kaayo”
“Miss unsaon pag limpyo ug
tarong ani dili diay sabon ra
og tubig?”
Objective:
- Patient’s non-verbal cues
showed fear and worry as
evidenced by hand tremor,
sweating, and panicking
- Patient shows interest in
learning more about the
proper surgical wound
care
OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Knowledge At the end of my 8 hour At the end of my 8 hour care,
deficit related care, the patient will be - Assess the patient’s - This will aid in establishing the objectives were met as
to lack of able to gain knowledge level of understanding learning needs and set evidenced by:
information regarding the proper on the proper care of a priorities.
regarding the surgical wound care as surgical wound
proper surgical evidenced by:
wound care
- Patient participated in the
- Participating in the - Provide and discuss - Active participation of the learning process
learning process options for care patient/couple is important
in the decision-making
process.
- Verbalizing - Give accurate - Patient Verbalized
understanding of information in easy-to- - To enable the patient or understanding of condition
condition understand terms couple to understand the
information completely.
- Verbalizing - Educate the patient on - Patient Verbalized
understanding of the proper - To ensure that the patient understanding of the proper
the proper preparations and is in control of the situation preparation and
preparation and equipments needed for and is given the proper equipments needed for
equipments needed care. care. care
for care
- Demonstrating the - Demonstrate the
proper surgical proper surgical wound - Helps the patient visualize - Patient demonstrated the
wound care care to the patient and and experience the whole proper surgical wound care
the family process.
Subjective: Acute Pain r/t At the end of my 8 hour
“Grabeha sa sakit miss” as disruption of care, patient will At the end of my 8 hour care,
verbalized by the patient skin and tissue verbalize decrease the objectives were met as
secondary to intensity of pain as evidenced by:
cesarean evidenced by: INDEPENDENT:
Objective: section
- Rates pain a 9 in a scale - Rates pain a 6 in a - Acknowledge client’s
of 0-10 scale of 0-10 pain and assess the - To develop a therapeutic - Verbalizes reduced
- Visible teary eyed characteristic and relationship with the patient discomfort or pain
- Irritable severity of pain and ensure individualized
- Able to ambulate with - Verbalizes reduced care.
assistance discomfort or pain - Rates pain a 6 in a scale of
- Restlessness noted 0-10
- Visible facial grimace - Educate on the proper
- Patient appears stressed - Demonstrates the deep breathing - The Health teaching will - Demonstrated deep
use of deep techniques and equip the patient with the breathing techniques
V/S: breathing relaxation knowledge on proper deep
techniques breathing techniques
BP=110/80
PR= 80bpm - Able to use - Demonstrate the - The use of pharmacological
RR= 22cpm pharmacological proper deep breathing - This helps the patient relax and non-pharmacological
T= 37.6 and non- techniques and lower the stress in the pain-relief strategies.
pharmacological body
pain-relief - Provide a comfortable
strategies. and calm environment - Promotes rest and ensures
the comfort of the patient
which is vital for recovery
and reduction of pain
- Provide non-
pharmacological pain - Acupuncture is a great
relief methods such as alternative to traditional
application of painkillers after surgery,
Cryotherapy (ice and and excellent natural
packs), acupuncture option to relieve pain.
and meditation or
distractions - Cold numbs the affected
area,
which can reduce pain and
tenderness. Cold can also
reduce swelling and
inflammation.

DEPENDENT:

- Provide
pharmacological pain - Tramadol is indicated for
relief medications such moderate to severe pain
as Tylenol - Tylenol (Acetaminophen)
(Acetaminophen) and is an analgesia used as
Tramadol pain reliever.
Hydrochloride
Subjective: Impaired
“ Sakit akong tiyan miss ga Comfort r/t Asses signs and
sigeg contract” Increased symptoms of infection
Uterine
Objective: Contractions
- Visible facial grimace pain
-

Risk for
Infection r/t
Break in the
skin