University of Cebu- Banilad

College of Nursing
Cebu City

Nursing Care Plan

Patient’s Name: Pahanunot, K.E. Hospital No:

Age: 25 Room No: 236A
Impression/Diagnosis: Low Segment Tranverse Cesarian Section Physician: Dr. Miel

CLINICAL PORTRAIT PERTINENT DATA

1. Assessment (general impression from head to toe) 1. History of present illness

2. Significant findings Hysterotomy and Laparotomoy due to footling breach

(+) pain (+) fatigue

2. Chief Complaints
3. Vital signs taken during the first contact with the patient
Verbalizes pain in the abdominal region with movement
T: 36.4 celsius
R: 11 3. Health History relevant to the present illness
P: 98 bpm
BP: 110/72 NONE
02: 65%
4. Vital signs taken During admission

NONE

5. Laboratory results Regardless of the findings

WBC count higher after parturition

 CUES NURSING SCIENTIFIC GOAL AND NURSING RATIONALE OF EVALUATION
DIAGNOSIS BASIS OUTCOME ACTION AND NURSING
CRITERIA NURSING ORDERS
ORDERS

Subjective Data: Postoperative pain Postoperative pain Goal: After 2 days Independent: Goal Met:
related to Low after CS is still of nursing A- Assess - To detect or Patient was able
The patient has Segment poorly controlled intervention, the patient’s blood monitor medical to stand and walk
mentioned that Transverse and results in patient will be able pressure, problems without assistance
her abdominal Cesarean Section. adverse outcomes to ambulate temperature, after 8 hours of
area really hurts. in the wellbeing of without further respiration, and nursing
both the mother complication. oxygen intervention. And
The patient has and her was able to
mentioned that newborn.Several Outcome Criteria: manage the
she was reluctant studies have After 8 hrs of P- Develop a plan - For management situation while
to move around revealed a high nursing aiming for the of pain maintaining
due to the pain prevalence of intervention, the patient to reduced physical health.
she felt. moderate to patient will be able abdominal pain
severe to: Goal Partially
Objective Data: postoperative pain Met::
(78-93%) after 1. Change I- Encourage - To improve blood Patient was able
The patient looks CS. (Demelash et sleeping patient for flow and aid to sleep peacefully
scared trying to al., 2022) position or ambulation quicker wound while vocalizing
move around. A Cesarean rotate healing minor pain.
section, or resting
The patient C-section, is the positions in Goal Not Met:
appears to be alternative option the bed Patient was not
hopeless at first to vaginal birth. In without able to sit erect
due to the pain. this type of vocalizing without verbalizing
delivery your baby pain. pain from recent
The patient’s pain is taken out 2. Sit erect cesarian section.
score was 7 out of through an without
10. incision made verbalizing
through the lower pain from
After a few hours, abdominal wall. recent
the patient has Once the cesarian
started to procedure is section
ambulate despite complete, it is operation.
voicing out her normal for you to 3. Stand and
pain. feel sick, weak, walk with
groggy and even assistance.
After a few hours, itchy - these are 4. Manage
the patient was all side effects of situation.
able to walk the anesthetics 5. Maintain
around. and should be physical
expected. well-being.
(Williams, E. H.,
2023)
 REFERENCES

BOOKS:

INTERNET SOURCES:

Demelash, G., Berhe, Y., Gebregzi, A. H., & Chekol, W. B. (2022, January 1). Prevalence and Factors Associated with Postoperative

Pain After Cesarean Section at a Comprehensive Specialized Hospital in Northwest Ethiopia: Prospective Observational Study.

Open Access Surgery; Dove Medical Press. https://doi.org/10.2147/oas.s347920

Yilmaz, F. M., Mathyk, B. A., Yildiz, S., Yenigul, N. N., & Saglam, C. (2018, March 21). Postoperative pain and neuropathy after

caesarean operation featuring blunt or sharp opening of the fascia: a randomised, parallel group, double-blind study. Journal of

Obstetrics and Gynaecology; Informa. https://doi.org/10.1080/01443615.2018.1437125

The Effects of C-Section Pain. (n.d.). Dr. Eric H. Williams.

https://www.baltimoreperipheralnervepain.com/blog/the-effects-of-c-section-pain.cfm