NURSING CARE PLAN

MATERNAL AND CHILD NURSING RLE | OB WARD

Presented by: Llamera, Claire

BSN 2C

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (02) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
 NURSING CARE PLAN
Name of Patient: Ma. Sebullen Age: 34 Name of Student: Llamera, Claire D. Level: BSN 2C Clinical Instructor: Sir, Randolph Alacantara

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain / impaired Short term: Dependent: Goal met.
Comfort related to ● After 24 hours of ● Giving medications ● Medications such as
The patient verbalized surgical trauma as nursing according to the analgesics or painkillers Short term:
“Bumuka yung tahi ko. evidenced by verbal intervention the healthcare provider’s can help reduce pain and After 24 hours of nursing
Masakit pa rin hanggang
reports and facial mask patient will feel recommendations or discomfort, allowing the intervention the patient
ngayon, lalo na kapag
nililinis” of pain reduced orders patient to rest and recover has felt reduced
discomfort or more comfortably. By discomfort and pain as
Objective: pain addressing the pain and evidenced by verbal
discomfort, medication can reports and a reduction
● Patient appears also help improve the in the facial mask of pain.
to be in pain patient's overall well-being
when Long term: and promote healing
moving around ● Within a week of Long term:
nursing Independent: Within a week of nursing
Vital signs:
intervention the ● Assess the client’s vital ● Vital signs can provide intervention the patient
● Temp: 36.5°C
● BP: 108/80 patient will be signs for signs and important information about were able to improve
mmHg able to improve symptoms of infection. the client's overall health overall comfort and
● RR: 19 cpm overall comfort and can indicate the reduced the frequency
● PR: 76 BPM and reduce the presence of an infection. and intensity of pain
frequency and Monitoring vital signs such episodes and has
intensity of pain as temperature, heart rate, performed appropriate
episodes and will and blood pressure can wound care interventions
perform help us identify any to protect and heal
appropriate abnormal changes that surgical incisions as
wound care may be indicative of an evidenced by
interventions to infection. By regularly enhance mobility and
assessing vital signs, we physical functioning and

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (02) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
 protect and heal
surgical incisions.
● Assess the surgical
incision and note for signs
of poor healing.
● Encourage the client to
verbalize feelings about
pain.
● Teach and demonstrate
proper relaxation
techniques—position for
comfort as possible.
Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (02) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
can detect infections early incision site healing
and initiate appropriate without signs of infection.
interventions to prevent
further complications.
● Wound characteristics like
color, size, drainage, and
odor must be assessed to
determine if a developing
infection is present. Pale
tissue color can indicate
circulatory and oxygenation
problems, while erythema,
swelling, drainage, or foul
odor can indicate infection.
● Allow the client to verbalize
her perceptions about pain
and acknowledge the pain
experience. Pain is a
subjective experience and
cannot be felt by others.
Convey acceptance of the
client’s response to pain.
● By teaching patients how
to relax and find
comfortable positions, they
can better manage their
pain and improve their
overall comfort. This can
also help reduce the
 intensity and frequency of
pain episodes.

● Encourage adequate rest ● Rest allows the body to

period. conserve energy, reduce
stress, and promote tissue
repair. It also helps to
alleviate pain and
discomfort, improve overall
well-being, and enhance
the body's ability to fight off
infections. Adequate rest
periods can also help to
prevent complications and
promote a faster recovery
after surgical trauma.

● Discuss with family ways ● Emotional and

to assist the client and psychological support
reduce the pain provided by the family can
help in recovery.

● Encourage proper wound ● The incision site must be

care. cleaned as instructed to
improve tissue integrity and
promote proper wound
healing.

● Instruct the patient to ● Strenuous activities can

avoid driving, lifting, or add pressure on the
performing strenuous abdomen and the surgical
activities. site and may cause

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (02) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus

Collaborative:
● Dietary consultation with
dieticians/nutritionists to
provide appropriate
nutritional support to
improve overall wound
healing
Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (02) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
complications like bleeding,
wound dehiscence, and
delayed healing.
● Poor nutritional intake can
increase the risk of delayed
wound healing and
impaired tissue integrity
from C-section surgery.
Protein is especially
important for new cell
formation at the surgical
incision site.