ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Acute pain Abdominal After 3 hours - Establish - To have a good After 3 hours of
“masakit yung related to incision and of nursing rapport nurse-client nursing
buong tiyan ko. disruption of uterine incision intervention, - Monitor vital relationship interventions,
Parang skin and can cause patient will signs - To establish the patient
parehong labas tissue alteration of the verbalize - Inspect skin on baseline data verbalized pain
at loob dahil sa secondary to skin. Skin is the decrease daily basis and - To determine decreased from
tahi at kabag” caesarean body’s first line pain intensity observe unusual ties and a scale of 7/10
As verbalized by section of defense from 7/10 to changes report it to to 5/10 as
the patient against foreign 4/10, patient - Provide physician for evidenced by
materials that will comfort by prompt (-) facial grimace
Objective: can be participate in helping patient treatment (-) guarding
 Pain scale = considered prevention to sit, stand lay - To avoid injuries behaviour
7/10 injuring agents. measures on bed and go or accidents Can ambulate
 Facial Once the skin is and to toilet or walk when patient with no
grimace disrupted, this treatment, around ambulates assistance
 Guarding will put a person maintain - Provide - Calm
behaviour at risk since it physical well- comfortable environment Goal partially
 Vital signs: may become a being and environment helps promote met
BP = 140/80 good medium has ability to by cleaning bed likelihood of
PR = 102 for bacterial manage and proper decreasing pain,
RR = 29 growth. situation ventilation anxiety and
T = 36.7 Caesarean - Instruct to put discomfort
section, like any pillow on the - To check for
other surgical abdomen when diastasis recti
procedures, coughing or and protect the
includes moving area of incision
invasion of the to improve
inside body. comfort.