XI.

NURSING CARE PLAN

Post-operative NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME

Subjective: Acute pain r/t STG: Independent: Goal met. After
“Sobrang sakit,” as disruption of skin After 1-2hr of 2hrs of nursing
verbalized by the and tissue nursing - Established rapport. -To have a good intervention, the
patient. secondary to intervention, nurse-client patient verbalized
cesarean patient will relationship pain decreased
Objective: section. verbalize - Monitored vital signs. from a scale of 8/10
-Pain scale= 8/10 decrease intensity -To establish a – 3/20 as
-Teary eyed of pain from 8/10 - Assessed quality, baseline data evidenced by
-(+) guarding to 3/10. characteristics, (-) facial grimace
behavior severity of pain. -To establish (-) guarding
-(+) facial grimace baseline data for behavior.
-Irritable comparison in Frequent small
-Pale palpebral making evaluation talks with significant
conjunctiva and to assess for others
-Skin warm to - Provided comfortable possible internal
touch environment – bleeding.
-V/S taken as changed bed linens
follows: and turned on the -Calm environment
BP= 110/80 fan. helps to decrease the
PR= 80 anxiety of the patient
RR= 22 and promote
T= 37.6 - Instructed to put pillow likelihood of
on the abdomen decreasing pain.
when coughing or
moving. - To check for
diastasis recti and
protect the area of
the incision to
improve comfort. And
to initiate
nonstressful muscle-
 setting techniques
and progress as
tolerated, based on
- Instructed patient to the degree of
do deep breathing separation.
and coughing
exercise. - For pulmonary
ventilation, especially
when exercising, and
to relieve stress and
- Provided diversionary promote relaxation.
activities. Initiate
ankle pumping, - To promote
active lower circulation, prevent
extremity ROM, and venous stasis,
walking prevent pressure on
the operative site.
Collaborative:
- Administer analgesic
as per doctor’s
order. -Relieves pain felt by
the patient
ASSESSMENT DIAGNOSIS NURSING PLANNING INTERVENTION RATIONALE EVALUATION
ANALYSIS
Subjective: Risk for Due to an STG: Independent
- none infection related elective After 4 hours of -Monitor vital -To establish a Patient is
inadequate cesarean nursing signs baseline data expected to be
Objective: primary section, intervention, free of
- dressing dry defenses patient’s skin patient will be -Inspect dressing -Moist from infection, as
and intact secondary to and tissue were able to and perform drainage can be a evidenced by
-V/S taken as surgical incision mechanically understand wound care source of infection normal vital
follows: interrupted. causative signs and
T: 37.3 Thus, the factors, identify - Monitor white - Rising WBC absence of
P: 80 wound is at risk signs of blood count (WB indicates body’s purulent
R: 19 of developing infection and efforts to combat drainage from
BP: 120/80 infection. report them to pathogens; wounds,
health care normal values: incisions, and
provider 4000 to 11,000 tubes.
accordingly. mm3

LTG: - Monitor -these are signs

After 2-3 days Elevated of infection
of nursing temperature,
intervention, Redness,
patient will swelling,
achieve timely increased pain,
wound healing, or purulent
be free of drainage at
purulent incisions
drainage or
erythema, be - Wash hands -Friction and
afebrile and be and teach other running water
free of infection. caregivers to effectively remove
wash hands microorganisms
before contact from hands.
with patient and Washing between
between procedures
procedures with reduces the risk of
patient. transmitting
pathogens from
one area of the
body to another

- Encourage fluid - Fluids promote

intake of 2000 ml diluted urine and
to 3000 ml of frequent emptying
water per day of bladder;
(unless reducing stasis of
contraindicated). urine, in turn,
reduces risk of
bladder infection
or urinary tract
infection (UTI).

- Encourage - These measures

coughing and reduce stasis of
deep breathing; secretions in the
consider use of lungs and
incentive bronchial tree.
spirometer. When stasis
occurs, pathogens
can cause upper
respiratory
infections,
including
pneumonia.

Independent: -Antibiotics have

-Administer bactericidal effect
antibiotics that combats
pathogens
 NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Objective Cues:
 Patient has Risk for Short Term INDEPENDENT After 8º of
not yet constipation r/t Goal: INTERVENTIONS: nursing
eliminated post pregnancy  Ascertain normal  This is to interventions, the
since 2° cesarean Within 8º of bowel functioning of determine the patient was able
delivery the patient, about normal bowel
section nursing to identify
 Absence of how many times a pattern
bruit sounds interventions, measures to
day does she
 Normal the patient will prevent infection
defecate  To increase the
pattern of be able to  Encourage intake of as manifested by
bulk of the
bowel has demonstrate foods rich in fiber stool and client’s
not yet behaviors or such as fruits facilitate the verbalization of:
returned lifestyle changes passage “Iinom ako ng
to prevent through the maraming tubig
developing colon at kakain ng
problem  Promote adequate  To promote prutas para
fluid intake. moist soft stool makadumi ako.”
Suggest drinking of
warm fluids,
especially in the
Long Term Goal:
morning to
stimulate peristalsis  To stimulate
Within 3 days of  Encourage contractions of
nursing ambulation such as the intestines
interventions, walking within and prevent
the patient will individual limits post operative
be able to complications
maintain usual  However, since she  To avoid stress
has had cesarean, on the
pattern of bowel
also encourage cesarean
functioning adequate rest incision/ wound
periods
COLLABORATIVE:

 Administer bulk-
forming agents or  To promote
stool softeners such defecation
as laxatives as
indicated or
prescribed by the
physician