CUES NURSING DIAGNOSIS PLANNING INTERVENTION
S: Acute pain related to disruption After nursing interventions, 1. Establish rapport.
“ sakit2 paman ahong saman” of skin and tissue secondary to patient will be able to verbalize 2. Monitor vital signs
as verbalized by patient. ceasarian section decrease intensity of pain from 3. Assess quality,
7/10 to 3/10. characteristics, severity of
O: pain.
• Pain scale – 7/10 4. Provide comfortable
• Teary eyed environment.
• (+) guarding behavior 5. Instruct patient to put pillow
• (+)facial grimace on the abdomen when
• Slightly irritable coughing or moving.
6. Provide diversionary
• Skin warm to touch
activities. Initiate ankle
• V/S are as follows: pumping, active lower
BP- 140/100 extremity ROM, and
Temp.- walking.
37 C
Pulse- 7. Anticipate need for pain
relief. Respond immediately
78 bpm
RR- to complaint of pain.
32 cpm 8. Eliminate additional
stressors or sources of
discomfort whenever
possible.
9. Provide rest periods to
facilitate comfort, sleep, and
relaxation.
10. Give analgesics as ordered,
evaluating effectiveness and
observing for any signs and
symptoms of untoward
effects.
Source:
RATIONALE EVALUATION
1. To have a good nurse-
client relationship.
2. To establish a baseline
date
3. to establish date fot
comparison in making
evaluation and to asses
for possible internal
bleeding
4. Calm environment
helps to decrease the
anxiety of the patient
and promote like hood
of the pain
5. To check for diastasis
recti and protect the
area of the incision to
improve comfort. .
6. One can most
effectively deal with
pain by preventing it.
Early intervention may
decrease the total
amount of analgesic
required.
7. The patient’s
experiences of pain may
become exaggerated as
the result of fatigue. In
a cyclic fashion, pain
may result in fatigue,
which may result in
 exaggerated pain and
Nursing Pocket Guide exhaustion. A quiet
By: Murr environment, a
Moorhouse darkened room, and a
Doenges disconnected phone are
all measures geared
toward facilitating rest.
9. Promote circulation,
prevent venous stasis, and
prevent pressure on the
operative site.
8. To decrease anxiety in
the patient.
9. Patients may experience
an exaggeration in pain
or a decreased ability to
tolerate painful stimuli
if environmental,
intrapersonal, or
intrapsychic factors are
further stressing them.
10. Pain medications are
absorbed and
metabolized differently
by patients, so their
effectiveness must be
evaluated from patient
to patient. Analgesics
may cause side effects
that range from mild to
life-threatening.