ASSESSMENT INTERVENTION

EVALUATION

CUES NURSING SCIENTIFIC PROBLEM NURSING

DIAGNOSIS EXPLANATION STATEMENT INTERVENTION RATIONALE
(GOAL)

Subjective: Self care Incisions or After 2 hours of Independent: After 2 hours

“Hindi pa ako deficit related surgical trauma nursing 1. Note whether 1. To assess of nursing
nakakaligo kasi to pain in the causes pain due intervention, the deficit is discharge intervention,
mahirap site of to an injury to patient will be temporary or needs the patient is
bumangon at incision, the nerves and able to perform permanent, 2. Personal be able to
masakit pa ung decrease tissues. selfcare activities should care perform
tahi ko. Ang strength and within level of own increase of assistant is selfcare
ginagawa ko, endurance as Unrelieved ability, as decrease part of activities within
puro banyos evidenced b acute evidenced by with time. nursing care level of own
lang po muna” verbalization postoperative proper hygiene 2. Perform of and should ability, as
as verbalized by of pain and pain leads to and self assist with not be evidenced by
the patient. inability to development of independence. meeting neglected proper hygiene
perform chronic pain client needs while self and self
bathing syndromes and 3. Promote care is independence.
Objective individually. increased clients SO promoted
 Difficult complications. participation and
moving in desired integrated
 Weakness goals and 3. Enhances
 Difficult decision commitment
accessing making to plan,
bathroom 4. Practice and optimizing
and promote outcomes,
fastening short term and
clothes goal setting supporting
 and recovery and
achievement health
5. Identify promotion
energy 4. To recognize
saving that todas
behaviors access is as
(Sitting important as
instead of an long term
standing), goals,
Provide accepting
mobility ability to do
assistance to one thing at
bathroom or a time.
offer urinal 5. Ensure the
as indicated safety of the
6. Provide patient
privacy 6. To enhance
7. Assist client self-esteem,
or teach the or improve
SO to clean ability to
the site of urinate or
incision defecate.
appropriately 7. To prevent in
fection
 ASSESSMENT INTERVENTION
EVALUATION

CUES NURSING SCIENTIFIC PROBLEM NURSING

DIAGNOSIS EXPLANATION STATEMENT INTERVENTION RATIONALE
(GOAL)

Subjective: Acute pain Incisions or At the end of 1 Independent: After 1 hour of

“Sumasakit related to surgical trauma hour nursing Assessed and To obtain base line nursing
yung tahi pag surgical causes pain due interventions the monitored vital data and monitor interventions
gumagalaw trauma as to an injury to patient will report signs changes in patient. the goal was
ako” as evidenced by the nerves and pain is relieved/ fully met ,the
verbalized by verbal report tissues. controlled and Assessed location, Data can help patient
the patient. of pain and looking relaxed. characteristics, indicate the suitable reported pain
 Pain scale pain scale of Unrelieved frequency, severity choice for as relieved,
of 6/10 6/10. acute and duration of pain treatments and looking
 postoperative interventions. relaxed and no
pain leads to guarding
Objective development of Provided comfort To provide behaviour.
 Facial chronic pain measures nonpharmacologic
grimace syndromes and pain management.
 Guarding increased
behaviour complications. Encouraged patient To prevent fatigue
 Irritability to rest or sleep
 VS:
BP: 100/70 Dependent:
PR: 73 Administered Necessary for
RR: 24 medications treatment of
O2Sat; 96 particularly underlying cause.
Temp; 36.7C analgesics as
prescribed.
 NURSING CARE PLAN- CESAREAN SECTION
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
EXPLANATION
SUBJECTIVE: Anxiety and fear Preoperative anxiety is After 30 minutes of INDEPENDENT: After 30 minutes of
“Gusto ko sana normal related to often described as an nursing intervention, Assessed psychological The greater the client perceives nursing intervention,
response to events and the threat, the greater her
delivery kaso need ko development of uncomfortable, tense the patient will be availability of support anxiety level. Women who are
the patient was able to
na daw ma CS kaya complications as unpleasant mood able to appears relax system. extremely worried about the appears relaxed and
kinakabahan ako kase evidenced by before surgery, an and express decrease cesarean birth may need a expressed decrease
unang pagbubuntis ko expressed concerns emotional response to anxiety after detailed explanation of the anxiety after
pa naman ito” as regarding a potential challenge explaining cesarean procedure to reduced their explaining cesarean
anxiety to a tolerable level.
verbalized by the consequences or threat to reality. birth birth
patient. Preoperative anxiety Determined stress level and Provides a database to build on
itself is not a mental learning needs to provide information that will
illness but studies decrease anxiety. Overwhelming
have confirmed that or persistent fears result in
excessive stress reactions.
the occurrence of
preoperative anxiety Noted and validated Validation helps the nurse and
OBJECTIVE: were positively expressions of fear, distress, the client deal realistically with
correlated. or feeling of helplessness. fear.
o Age of patient:
20 years old
o Restlessness Remained with the client, Therapeutic communication
o Inattentiveness and stay calm. Speak slowly helps to reduce interpersonal
o Stiff posture and convey empathy. transmission anxiety and shows
care for the client or couple.
o Tense
Allotted time for privacy. Allows the client or couple to
process information, organize
resources, and cope effectively
Guided the client through
preoperative nursing care Familiarization with preoperative
nursing care can significantly
reduce the client’s anxiety, heart
rate and blood pressure
(Mostafayi et al., 2021)
 NCP

ASSESSMENT INTERVENTION
EVALUATION

CUES NURSING SCIENTIFIC PROBLEM NURSING

DIAGNOSIS EXPLANATION STATEMENT INTERVENTION RATIONALE
(GOAL)
Risk for Infection at the After 3 hours  Monitored  To obtain baseline Goal was fully met
Subjective: infection incision site can of nursing Vital data after 3 hours of
” Medyo di ako related to cause intervention Signs: nursing
komportable at surgical inflammation, the patient will Temp., intervention:
namumula at incision as leading to pain, be: HR, RR
namamaga sa evidenced by tenderness, and  Close observation  The patient
bandang opera elevated discomfort.  Free  Assess of the surgical was free
ko”, as white blood Inflammatory from incision incision site helps from signs
verbalized by cell count mediators and signs site. identify any signs and
the patient. immune cells and of redness, symptoms
are recruited to sympto swelling, warmth, of
the infected ms of or purulent infections.
Objective: area, resulting infection drainage, which
 Swelling in localized s are indications of  The patient
in the symptoms. infection. can now
site of  The demonstrat
incision patient  Reduces risk of e
will  Provide ascending urinary techniques
 Elevated demons regular tract infection. to promote
White trate urinary preventive
blood underst catheter/p measures.
 cell anding erineal
count of care.
infection  Hand hygiene is
 Guarding preventi  Promote critical in
behavior on Hand preventing the
measur Hygiene transmission of
RR: 24 es. infectious agents.

 Proper wound
 Provide care promotes
Wound healing and
Care reduces the risk
of infection.

 Administering
 Administer antibiotics as
prophylacti prescribed by the
c healthcare
antibiotics provider helps
as per eliminate or
doctor’s control potential
order infectious
organisms,
reducing the risk
of infection.