Abegail P.

Mier BSN 2 - C

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjectve: Acute pain related to Short term goal: Independent: Goal met:
“Ga sakit akong disruption of skin and After 2-3 hours of  Established  To have a good After 2 hours of
abdomen” as tissue secondary to nursing intervention, rapport. nurse-client nursing interventio,
verbalized by the cesarean section. patient will verbalize  Monitored vital relationship. the patient verbalized
patient. decrease intensity of sings.  To establish pain decreased from
baseline data.
pain from 8/10 to  Assessed quality, a scale 8/10 - 3/10 as
 To establish
Objective: 3/10. characteristics, baseline data for evidenced by (-)
severity of pain. comparison in guarding behavior (-)
 Pain scale - 8/10  Provided making evaluation facial grimace.
 Teary eyed comfortable and to assess for Frequent small talks
 (+) guarding environment - possible internal with signnificant
behavior arranged bed bleeding. others.
 (+) facial grimace linens and turned  Calm environment
 Pale palpebral on the air helps to decrease
conjunctiva conditioner. the anxiety of the
patient and
 Skin warm to  Instructed to put
promote likelihood
touch pillow on the of decreasing pain.
 VS taken as abdomen when  To check the
follows: couhing or diastais recti and
BP: 110/80 mmHg moving. protect the area of
PR: 106 bpm  Provided the 14 the incision to
RR: 20 bpm rights of improve comfort.
Temp. 36.2 C medication  To check to see
O2Sat: 96% administration. that the medication
is correctly
prescribed and
dispensed before
administration.

Patient’s name: Rea Magdayao 27yrs. old

Dx: Post CS G 1 P 0
Clinical Instructor: Matilde Latorre RN, MN