NURSING CARE PLAN

Post-operative NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME

Subjective: Acute pain Short Term: Independent: Goal met. After
“Hindi ako related to After 1-2hr of 2hrs of nursing
makagalaw disruption of skin nursing - Established rapport. -To have a good intervention, the
masakit yung and tissue intervention, nurse-client patient verbalized
pinagoperahan ” secondary to patient will relationship pain decreased
as verbalized by cesarean verbalize - Monitored vital from a scale of 6/10
the patient. section. decrease intensity signs. -To establish a – 3/20 as
of pain from 6/10 baseline data evidenced by
Objective: to 3/10. - Assessed quality, (-) facial grimace
-Pain scale= 6/10 characteristics, -To establish (-) guarding
-Teary eyed severity of pain. baseline data for behavior.
-(+) guarding comparison in Frequent small
behavior making evaluation talks with
-(+) facial grimace and to assess for significant others
-Irritable possible internal
- -Skin warm to bleeding.
touch - Provided
- V/S taken as comfortable -Calm environment
follows: environment – helps to decrease the
BP= 110/80 changed bed linens anxiety of the patient
PR= 80 and turned on the and promote
RR= 16 fan. likelihood of
T= 36.4 decreasing pain.

- For pulmonary
ventilation, especially
when exercising, and
- Instructed patient to to relieve stress and
do deep breathing promote relaxation.
and coughing
 exercise. - To promote
circulation, prevent
- Provided venous stasis,
diversionary prevent pressure on
activities. Initiate the operative site.
ankle pumping,
active lower
extremity ROM, and
walking -Relieves pain felt by
the patient
Collaborative:
- Administer
analgesic as per
doctor’s order.