ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Acute pain related to Short Term INDEPENDENT INDEPENDENT GOAL MET
Data: surgical incision due Goal: 1. Established 1. To have a good Short Term Goal
Reported pain to cesarean birth as After 4 hours rapport nurse to client
with intensity 8 evidenced by facial of effective 2. Monitored vital relationship Goal met.
on the standard grimace with a pain nursing signs 2. To establish a
pain scale where 3. Assessed quality, baseline data. After 4 hours of nursing
scale of 8. interventions,
1 has the least characteristics, 3. To establish intervention, the patient was able
the patient will severity of pain. baseline data for
pain and 10 has to experience lesser pain and
be able to 4. Advised patient comparison in above a tolerable level as
the severe pain
experience a to do breathing making evaluation manifested by:
Objective data: lesser pain and exercises. 4. To decrease - pain scale of 4/10
above a 5. Educate and discomfort - no facial grimace
Vital Signs: tolerable level adequate rest 5. To avoid stress on - calm and cooperative
as manifested periods the cesarean
T – 36. 4 C 6. Discuss with incision/wound Long Term Goal
by:
family ways to 6. Emotional and
P – 102 bpm 1. Pain scale
assist the client physiological Goal met.
of at least and reduce the support by the
R – 18 brpm 4/10 pain. family can help in After 3 days of effective
BP – 120/80 2. No facial DEPENDENT recovery and reduce nursing interventions, the
mmHg grimace 1. Administer postpartum pain.
patient achieved timely wound
3. Slight analgesic as DEPENDENT healing, free of infection and
irritability. ordered by 1. allows for the was able to move without much
physician. regulation of pain assistance from others.
Long Term and
Goal inflammation, as
After 3 days well as tension in
of effective the muscles,
nursing which enhances
interventions, client comfort
the patient and encourages
will: healing
1. Achieve 2. relieves
timely discomfort and
wound promotes healing
healing of the
2. Able to incision/wound.
move
without
much
assistance
from
others.