EMILIO AGUINALDO COLLEGE

School of Nursing

NURSING CARE PLAN

NAME: PATIENT NAME: AGE: 28 y/o DATE: 3/12/2022

STUDENT #: DIAGNOSIS: Deficient Knowledge GENDER: Female ROOM NO. 606

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION

Subjective: “ano ba yung

C section ndi ako
Deficient knowledge After 4 hours of nursing - Provide accurate - The stress of the Goal met:
familiar sa procedure”
related to care: information in easy-to- situation can
misinterpretation of understand terms and affect the client’s
information as evidenced clarify misconceptions. ability to After 4 hours of nursing
by request for - The client states understand the care:
information. that they feel well information
prepared for required to make
cesarean birth. - Encourage the couple to informed - The client states
ask questions and decisions. she is prepared
verbalize their - Provides an for cesarean
understanding of the opportunity to birth
matter. assess and
evaluate the
client’s or
couple’s
understanding of
- Review indications
Objective: the situation.
necessitating alternative
birth methods. - Cesarean birth
should be viewed
 EMILIO AGUINALDO COLLEGE
School of Nursing

VS as an alternative
BP:110/80 and not an
- Explain preoperative
abnormal
T:36.7 procedures in advance
and present rationale as situation to
PR:87 appropriate. enhance maternal
and fetal safety
RR:20
and well-being.
- Review the necessity for - Explanation of
postoperative measures. the logical
reasons why a
particular choice
- Educate the client was made is vital
preoperatively and in preparation for
reinforce learning the procedure.
postoperatively,
including - Educate the
demonstration of leg client about the
exercises, proper rationale behind
coughing, deep necessary
breathing techniques, postoperative
incentive spirometry, measures such as
splinting, and indwelling
abdominal tightening bladder catheter,
exercises. IV fluid
administration,
and placement of
- Stress anticipated an epidural
sensations further catheter for post-
procedure pain
EMILIO AGUINALDO COLLEGE
School of Nursing

during the delivery and relief (if

recovery period. preferred by the
client).
- Provides routine
- Discuss and develop a
to prevent
postoperative pain
complications
management plan and
associated with
review the use of the
venous stasis and
pain scale.
hypostatic
pneumonia and
lessen stress on
the operative site.
Abdominal
tightening
reduces distress
associated with
gas formation
and abdominal
distension.
Periodic deep
breathing
exercises fully
aerate the lungs
and help prevent
stasis of lung
secretions.
- Knowing the
possible
 EMILIO AGUINALDO COLLEGE
School of Nursing

outcomes helps
prevent
unnecessary
anxiety.
Preoperative
teaching aims to
acquaint the
client with the
cesarean
procedure and
any special
equipment used.
- Developing a
pain management
plan with the
client increases
the likelihood of
successful pain
management.

DATA FOCUS ACTION RESPONSE

 EMILIO AGUINALDO COLLEGE
School of Nursing

“Ano ba yung c section hindi ko alam Deficient Knowledge - Provide teaching and - Patient states that she is ready
kung paano ginagawa yon” information about the for the operation
procedure
- Explain the perioperative
procedures that will be done
- Provide comfort to the patient
reassure her that everything
will be fine