Assessme Nursing (Rationale) Desire Nursing Justificati Evaluati
nt Cues Diagnosis Pathophysiol d Interventi on on
ogic / Outco on
Schematic
Diagram
me
Subjectiv After 8
e: Acute pain hours
“Ga sakit related to of
gid ya surgical nursing
tahi ko, incision after a care,
miss. As C-section birth the
in.” as as evidenced client
verbalize by facial is
d by the grimace, expect
patient. verbal report ed to:
of acute pain,
sweating -
Pain
scale:
9/10 as 0
the
lowest
and 10
the
highest.
Definition: Reference:
Objective
:
Facial
Grima
ce
Verbal
Source/
report Reference
of NANDA
acute
pain
Sweati
ng
Vital
Signs:
Temp:
36.6 c
PR: 98
bpm
RR: 15
cpm
BP:
120/70
Strength :
Weaknes
s:
Name of Student: _________________________________
Section and Group number: _______________________ NURSING CARE PLAN
Name of CI: _______________________________ ______
Area of Exposure: __________________Name of CI: _______________________________ ______
_____________