ASSESSMENT
DIAGNOSIS
Subjective: Acute pain related to
surgical trauma, post
“Masakit ang sugat ko cesarean section.
galing opera” as
verbalized by the client.
Pain scale of 10/10
Objective:
Blood pressure is at
100/60 mmHg.
Respiratory rate is 23.
Facial mask of pain is
observed.
NURSING OBJECTIVES INTERVENTIONS
Short-term goal:
After 4 hours of nursing
interventions, the client
will be able to:
Verbalize reduced
discomfort or pain.
Appear relaxed and can
rest or sleep.
Verbalize methods that
provide relief
Long-term goals:
After 2 days of nursing
intervention, the patient
will be able to report a
relief of pain as evidenced
by a pain scale rating of
2/10 or less, and will be
able to report a restored
health status as evidenced
by ability to perform
normal daily activities.
Assess location,
characteristics, frequency,
severity, and
onset/duration of pain.
Perform pain assessment
everytime the client
reports pain.
Monitor the client’s vital
signs.
Encourage adequate rest
periods.
Discuss with family ways
to assist the client to
reduce pain.
RATIONALE
CRITERIA
To indicate the suitable
choice of treatment and
guide interventions.
To investigate changes
from previous reports.
To note for signs of
tachycardia, hypertension,
and increased respirations.
To prevent fatigue and
recover appropriately.
For the family to provide
emotional and
psychosocial support to
help in recovery and
reduce postpartum pain.
EVALUATION
Short-term:;
After 4 hours of nursing
interventions, the client
was able to verbalize
reduced discomfort or pain
and the methods that
provide her relief. She
appears relaxed and is able
to rest and sleep.
Long-term goals:
After 2 days of nursing
intervention, the patient
was able to report a relief
of pain as evidenced by a
pain scale rating of
2/10.She is able to report a
restored health status,
evidenced by her ability to
perform normal daily
activities.