NURSING OUTCOME PLANNING NURSING INTERVENTIONS

ASSESSMENT CUES EVALUATION

DIAGNOSIS IDENTIFICATION INTERVENTIONS RATIONALE
 Pain scale of 5 Acute pain r/t After 1-2 hrs of nursing Independent:    
out of 10. disruption of skin intervention, patients -Promote perineal exercise -decrease After 2 hours of nursing
-(+) facial and tissue will verbalize decrease and comfortable stitting discomfort intervention the
grimace secondary to intensity of pain from position. verbalized pain
-Pale palpebral caesarean 5/10 to 2/10. -Assess quality, -To establish decreased from a scale
conjunctiva section. characteristics, and severity baseline data for of 5/10 to 2/10 as
-Skin warm to of pain. comparison in evidenced by (-) facial
touch. making evaluation grimacing.
-V/S taken as and to assess for Frequent small talks with
follows: possible internal significant others.
BP=110/70 bleeding.
PR=78 -Provide comfortable
RR=18 environment by changing -Calm environment
T=36.7 bed linens and turned on helps to decrease
the fan. the anxiety of the
patient and
promote likelihood
of decreasing pain.
-Instruct to put pillow on the -To protect area of
abdomen when coughing or the incision and to
moving. provide comfort

-Provide diversionary -To promote

activities. Initiate active circulation, prevent
extremity ROM, and walking venous stasis;
prevent pressure
on the operative
site.
Dependent:
1.Administer analgesic as -Relieves pain felt
per doctor’s order by the patient.
           

           

ASSESSMENT NURSING OUTCOME PLANNING NURSING INTERVENTIONS

EVALUATION
CUES DIAGNOSIS IDENTIFICATION INTERVENTIONS RATIONALE
       
Objective Cues: Risk for Within 8 hours of  Ascertain normal  This is to After 8 hours of nursing
 Patient has conspiration r/t nursing interventions, bowel functioning of determine interventions, the patient
not yet post pregnancy the patient will able to the patient, about the normal was able to identify
eliminated 2* caesarean demonstrate how many times a vowel measures to prevent
since section behaviours or lifestyle day does she pattern infections as manifested
delivery changes to prevent defecate  To by client’s verbalization of:
 Absence of developing problem  Encourage intake of increase “Iinom ako ng maraming
bruit food rich in fiber the bulk of tubig at kakain ng prutas
sounds such as fruits the stool para makadumi ako.”
 Normal  Promote adequate and
pattern of fluid intake. Suggest facilitate
bowel has drinking of warm the
not yet fluids, especially in passage
returned the morning to through the
 stimulate peristalsis colon
 Encourage  To promote
ambulation such as moist soft
walking within stool
individual limits

           

           

ASSESSMENT NURSING OUTCOME PLANNING NURSING INTERVENTIONS

EVALUATION
CUES DIAGNOSIS IDENTIFICATION INTERVENTIONS RATIONALE
     After 4 hours of -Monitor vital signs -To establish  
Objective: Risk for infection nursing care, the baseline data Patient is expected to be
Dressing dry and related to patient will be able to -inspect dressing and -Moist from free of infection as
intact. inadequate understand causative perform wound care drainage can be a evidenced by normal vital
-V/S taken as primary defences factors, identify signs source of infection. signs and absence of
follows: secondary to of infection and report -Monitor elevated -These are signs of purulent drainage from
BP=110/70 surgical incision. them to health care temperature, redness, infection. wounds, and incisions.
PR=78 provider accordingly. swelling, increased pain or
RR=18 purulent drainage at
T=36.7 incisions. -Friction and
-Wash hands and teach running water
significant others to wash effectively remove
hands before contact with microorganism
patient. from hands.

DEPENDENT -Antibiotics have

-Administer antibiotics bactericidal effect
that combats
pathogens.
           

           

ASSESSMENT NURSING OUTCOME PLANNING NURSING INTERVENTIONS

EVALUATION
CUES DIAGNOSIS IDENTIFICATION INTERVENTIONS RATIONALE
        
Infant is content Effective After 2 hours of shift, Assess mother’s Establish baseline After 2 hours of shift the
after feedings breastfeeding the client will be able knowledge with and direction for client demonstrated
Mother able to related to to demonstrate breastfeeding. teaching/planning effective techniques for
position infant at material effective techniques breastfeeding. And
breast to confidence for breastfeeding. For unrestricted verbalize understanding
promote The client will be able Keep infant with mother. breastfeeding of breastfeeding.
successful to: duration and
lactation frequency.
response (1) Verbalize
understanding Encourage mother to drink Adequate hydration
of at least 2000ml of fluid per
breastfeeding day.
techniques Provide different
(2) Promote Provide information methods for
effective needed. assessing/reinforcing
breastfeeding information and
behaviors enhances opportunity
for
learning/understandin
g
           

          2

ASSESSMENT NURSING OUTCOME PLANNING NURSING INTERVENTIONS

EVALUATION
CUES DIAGNOSIS IDENTIFICATION INTERVENTIONS RATIONALE
   Altered body  After 2 hours of  
temperature as nursing intervention Assess underlying condition To obtain The patient’s temperature
evidenced by the temperature of the and body temperature comparative subsided after 2 hours of
temperature of client will decrease baseline data and nursing intervention from
patient of 38.0 from 38.0-37.2 to assess 38.0 to 37.2 degree
degree Celsius. contributing Celsius.
Monitor vital signs. factors.
To assist with
measures to
Provide tepid sponge bath reduce body
temperature.
Wash hands with anti- May help reduce
bacterial soap before and fever.
after each care and activity. Reduces cross
Encourage proper hygiene. contamination and
prevents the
Encouraged to spread of infection.
breastfeeding to replace
those lost through sweating. To keep the baby
hydrated.

        Encourage changing of  To provide comfort  

clothes and fanning the and relaxation of
infant. the baby.