Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
“Hindi niya masyadong alam Knowledge deficit Short term goal: Independent: Goal: Met
ang mga operasyon na related to Psychomotor: Determine the Individual may not After 10minutes
gagawin sakanya” as unfamiliarity with After 10 minutes client’s ability be physically, of nursing
verbalized by the client’s information of nursing care, and barriers to emotionally or mentally care, patient has
husband. resources the client will be learning. capable at this time. able to
evidenced by able to demonstrate and
Objective Cues: request of participate in the understand the
• Need in information learning process information
further about the client’s Assess the level of May need to help regarding the
explanation disorder and its the client’s caregivers to learn. surgical procedur
on surgical capabilities and e
the procedur procedure. the possibilities
e of the situation.
•Different perception of the Affective: Provide information
surgical procedure After 10 minutes on the procedure and
of nursing care, Explain its complications.
Vital Signs: the client can the procedure to
BP= 170/100 mmHg verbalize the client’s
PR= 120 bpm understanding of support person. To provide reality-based
RR= 22 cpm the surgical facts.
T = 37.9 C procedure.
Prevent
Cognitive: information
After 10 minutes relevant to the
of nursing care, situation.
the client will be
 able to Discuss client’s
understand perception Client will feel
surgical needs. competent and
procedure respected.
involved in the
disorder.

Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
Acute pain r/t STG: Independent: Goal met.
Subjective: disruption of skin After 1-2hr of -To have a good After 2hrs of
“Sobrang sakit,” and tissue nursing - Established nurse-client nursing
as verbalized by the secondary to intervention, rapport. relationship intervention,
patient. cesarean section. patient will the patient
verbalize verbalized pain
Objective: decrease intensity - Monitored vital -To establish a decreased from
-Pain scale= 8/10 of pain from 8/10 signs. baseline data a scale of 8/10
-Teary eyed to 3/10. – 3/20 as
-(+) guarding behavior - Assessed -To establish baseline evidenced by
-(+) facial grimace quality, data for comparison in (-) facial
-Irritable characteristics, making evaluation and grimace
-Pale palpebral severity of pain. to assess for possible (-) guarding
conjunctiva internal bleeding. behavior.
-Skin warm to touch Frequent small
-V/S taken as follows: - Provided -Calm environment
BP= 120/90 mmHg comfortable helps to decrease the talks with
PR= 90 bpm environment anxiety of the patient significant
RR= 22 cpm and promotes others
T= 37.6 C likelihood of
decreasing pain.
– changed bed - To check for
linens and turned diastasis recti and
on the fan. protect the area of the
incision to improve
- Instructed to put comfort. And to initiate
pillow on the nonstressful muscle
abdomen when setting techniques and
coughing or progress as tolerated,
moving. based on the degree
of separation.
- Instructed - For pulmonary
patient to do ventilation, especially
deep breathing when exercising, and
and coughing to relieve stress and
exercises. promote relaxation.
- Provided - To promote
diversionary circulation, prevent
activities. Initiate venous stasis, prevent
ankle pumping, pressure on the
active lower operative site.
extremity ROM,
and walking.

Collaborative:
- Administer
analgesic as per -Relieves pain felt by
doctor’s order. the patient