NURSING BACKGROUND GOALS AND

ASSESSMENT NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE OBJECTIVES
Independent
SUBJECTIVE CUES: Acute pain Pain Stimulus- After 3 hours 1. Established  To have a good Goal met. After 3
“Musakit akong tahi related to visceral and of nursing rapport with the nurse- client hours of nursing
samot na ug mulihok surgical cutaneous interventions, patient. relationship. intervention, the
ko”, as verbalized by incision due to Fibers: Nociceptor the patient’s patient verbalized
the patient. caesarean (skin and internal pain scale will 2. Monitored vital  To establish a pain decreased
birth as organ)-Dorsal decrease from signs. baseline data. from a scale of
OBJECTIVE CUES: evidenced by Horn-reticular 6/10 to 3/10. 6/10 to 3/10 as
 Facial facial grimace formation (sleep evidenced by
Grimace with with a pain center)- Thalamus- 3. Assessed quality,  To establish (-) facial grimaced
pain scale of 4 scale of 6. Limbic Cortex- chracteristics, baseline data for (-) guarding
 Protective Cerebral Cortex- severity of pain. comparison in behavior, and
gesture to Perception of making frequent small
avoid pain in Noxious stimuli evaluation and to talks with
incision site assess for significant others.
noted possible internal
 Limited The harmful effects bleeding.
movements of unrelieved acute
noted pain can affect the 4. Provided comfort  To alleviate pain
 Expressive pulmonary, measures such as by promoting
behaviour cardiovascular, GIT, repositioning or non-
such as Endocrine system quiet pharmacological
sighing and can cause environment. pain
severe pain and it management.
may increase the
risk of developing 5. Instructed the  To distract
physiologic patient to use attention and
disorders. relaxation reduce tension.
techniques and
encourage
diversional
activity such as
listening to
music, watching
television and
socialization with
 others.

6. Changed bed  Calm

linens environment
and turned on the helps to decrease
fan. the anxiety of
the patient and
promote
likelihood of
decreasing pain.

7. Instructed to put  To check for

pillow on the diastasis recti
abdomen when and protect the
coughing or area of the
moving. incision to
improve comfort.
And to initiate
non-stressful
muscle setting
techniques and
progress as
tolerated, based
on the degree of
separation.

8. Instructed patient  For pulmonary

to do deep ventilation,
breathing and especially when
coughing exercising, and to
exercise. relieve stress and
promote
relaxation.

9. Initiated ankle  To promote

pumping, active circulation,
lower extremity prevent venous
ROM, and stasis, prevent
walking. pressure on the
 operative site.

10. Encouraged  To avoid stress

adequate rest on the caesarean
periods incision/ wound.

Dependent
 Administer  Relieves pain felt
analgesic as per by the patient.
doctor’s order.

Nursing Theories:

1. Environmental Theory by Florence Nightingale

- She believed the environment had a strong influence on patient outcomes, and many elements of her Environmental Theory. In the NCP
above, nursing intervention numbers 4, 5 and 6 utilize her theory wherein comfort measures should be provided to the patient such as
providing a quiet environment, promoting relaxation techniques, changing bed linens and turning on the fan. It is stated in her theory
that patients should have clean air and a temperature-controlled environment, noise reduction is necessary and bedding should be
changed and aired frequently in order to create the optimal conditions for the patient’s body to heal itself.

2. Interpersonal Theory by Hildegard Peplau

- She defines the nurse/ patient relationship evolving through orientation, identification, exploitation and resolution. Nurses enter into a
personal relationship with an individual when a felt need is present. In this NCP, this theory is being utilized from the start of the nursing
process which is the assessment phase until the evaluation phase. The mere assessment of a patient marks the beginning of the
orientation phase when a nurse introduces himself/herself to the patient and asking what he/ she needs. Nursing intervention numbers 1
and 3 utilize this theory wherein the nurse establishes rapport with the patient.

3. The System Model by Betty Neuman

- This theory focuses on the response of the client system to actual or potential environmental stressors and the use of several levels of
nursing prevention intervention for attaining, retaining and maintaining optimal client system wellness. She defines the concern of
nursing is preventing stress invasion. If stress is not prevented then the nurse should protect the client’s basic structure and obtain or
maintain a maximum level of wellness. In the NCP, nursing intervention numbers 7, 8, and 10 make use of this theory. These
interventions prevent stressful activities by doing coughing exercises, deep breathing exercises and providing adequate rest periods thus
promote patient’s wellness and fast recovery.
4. Unitary Human Beings by Martha Rogers
- She saw nursing as both a science and an art. Nursing seeks to promote symphonic interaction between the environment and the person,
to strengthen the coherence and integrity of the human beings, and to direct and redirect patterns of interaction between the person and
the environment for the realization of maximum health potential. Nursing intervention numbers 8 and 10 utilizes her theory. By doing
these tolerable exercises, and relaxation techniques, in this way the energy flows freely between the individual and environment.

5. Need Theory by Virginia Henderson

- She emphasized the importance of increasing a client’s independence to promote their continued healing progress after hospitalization.
She said that the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to
health or its recovery that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as
to help him gain independence as rapidly as possible. In my NCP, nursing intervention number 4 utilizes her theory by repositioning the
patient to minimize patient’s pain level. During this time, patient needs to be aided in doing such activities because she is still in pain, but
eventually little by little as tolerated the patient could do it by herself without any aid.

6. Self-Care Deficit Theory by Dorothea Orem

- Orem’s vision of health is a state characterized by wholeness of developed human structures and of bodily and mental functioning. It
includes physical, psychological, interpersonal and social aspects. In the NCP, nursing intervention numbers 7,8 and 9 utilize Orem’s
theory. The patient at this time is partially dependent to her significant others and health care provider especially when doing things for
her own such as turning to sides and performing personal hygiene because of the pain being felt when moving. Health teaching also is
being inculcated to her so that when the time comes that she can tolerate already the pain, she can do things on her own and eventually
become totally independent.

7. Adaptation Theory by Sister Callista Roy

- Callista Roy’s theory states that a person is in constant interaction with a changing environment. To cope with a changing world, person
uses both innate and acquired mechanisms which are biological, psychological and social in origin. To respond positively to environmental
changes, the person must adapt. There are many kinds of stimuli that a person encounters every day. In this patient’s situation, pain is
being felt upon moving because of the focal stimulus that is present which is the stitch caused by the caesarean section. In order for her
to adapt to this situation, she needs to divert her attention so that she will not focus on the stitch itself but on how she can cope up with
this situation. Nursing intervention numbers 4, 5 and 10 utilize Roy’s theory. Providing diversional activities such as listening to music,
reading, watching television, socializing as well as taking care of her baby are some of the many ways she can do in order to adapt to the
changing environment she is into. In addition, environmental factors also contribute to the way she adapts the situation, so by providing a
conducive environment, and strong support system; adaptation is hasten.