NCP FOR CAESARIAN DELIVERY (BREECH PRESENTATION) CUES/ASSESSMENT Subjective Cues: Makulog asin maluya pa an sakong pagmate dahil

sa paghiwa kan tulak ko as verbalized by the patient Objective Cues >Temp:____ 0 C >PR:_____bpm >RR:_____cpm >BP:_____mm/Hg >Rated pain as 4 to 6 out of 10 pain scale >Pain increases when move vigorously the incision site. >Wound dry, no discharges noted > Dressing and plaster were clean & no foul odor noted on the site NSG.DIAGNOSIS Acute pain related to abdominal incision secondary to surgery OBJECTIVE At the end of my nursing intervention of 8 hours duty the patient will be able to report pain is relieved and controlled. PLANNING By the 1 hour of my nursing intervention the client will: Report pain intensity from 4 to 6 will decrease at 2 to 3 from 0 to 10 pain scale. Participate in demonstratin g techniques to relieve pain INTERVENTION Independent: RATIONALE EVALUATION

Establish rapport to the client

To easily gain cooperation from the patient. To have baseline data and for comparison of future data To enhance patients selfesteem and to provide comfort to the patient. By getting the following information, we are assisting in differentiating cause of pain and providing information about disease progression/resolu tion, development of complications and effective interventions.

Monitor the vital signs

Perform bedside care

At the end of the shift goal is met as evidenced by the patient has able to manage pain, relieved and controlled from 4 to 6 to 2 to 3 on the pain rating scale.

Observe and document location, severity and character of pain. Promote bedrest

allowing patient to assume position in comfort

Bedrest in lowfowlers position to reduce intrabdominal pressure.

Employ nonphatmacologi c pain To prevent distraction dependency on such as medication for Music pain. therapy, imagery and etc. MEDICATION: NSAIDs

To relieve pain immediately