ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUAT

THE PROBLEM

Subjective: The patient had post- STO: Dx: STO:

operative pain in the
"Masakit yung tahi ko hypogastric region due to Within 30 minutes-1 hour  Observed guarding behavior of  To assess the onset of pain (Goal Met)
kapag gumagalaw ako". sutures and incisions made. of effective nursing the abdominal region and and the area where the pain
interventions, the patient expressive behavior while starts Within 30 m
Objective: will be able to: moving or changing positions 1 hour of e
Cesarean delivery (also nursing
 Guarding called a cesarean section or a) verbalize decrease in pain  Assessed ability to perform intervention
behavior C-section) is the surgical rated to 5/10 activities of daily living. patient ve
 Pain can limit the patient's
 Needs assistance delivery of a baby by an decrease i
ability to participate in self-
with activities incision through the b) relaxed facial rated as
care and function daily
like rising from expressions and body relaxed
mother's abdomen activities independently.
bed positioning. expressions
(belly) and uterus(womb).
 Pain rates 6/10  Measured pain through numeric  To determine degree of pain. body pos
This procedure is done c) participate in rating scale for severity
recommended relaxation while restin
when it is determined to be
techniques if pain sets able to pa
a safer method than a
again. Tx: recommend
vaginal delivery for the
Nursing Diagnosis: relaxation
mother, baby, or both.  Assisted with activities of daily  Help conserve energy and techniques
PAIN related to post- living and promoted comfort assist in daily activities until pain sets ag
In a cesarean delivery, an LTO:
operative procedure as and rest. client can independently do it
incision (cut) is made in the
manifested by facial
skin and into the uterus at Within 24 hours of effective
grimace, guarding  Fear and anxiety can
the lower part of the nursing interventions, the LTO:
behavior and verbal decrease the client’s
mother’s abdomen. The patient will:  Implement measures to reduce
report of pain felt in the threshold and tolerance for
fear and anxiety (Goal Met)
hypogastric region rated incision in the skin may be a) perform relaxation pain and thereby heighten the
as 6/10. vertical (longitudinal) or techniques independently perception of pain. In Within 24
transverse (horizontal), and when pain sets. addition, pain management effective
the incision in the uterus methods are not as effective intervention
may be vertical or b) able to rest, display if client is tense and unable patient was
transverse. reduced tension, and sleeps to relax. independen
A transverse incision comfortably. relaxation
extends across the pubic  Increase in the normal value techniques
c)verbalize of respiratory rate, pulse rate, deep-breath
hairline, whereas, a vertical nonpharmacological blood pressure, oxygen asks for
incision extends from the methods provided relief  Monitored vital signs like
saturation and temperature assistance
navel to the pubic hairline. respiration rate, blood pressure,
can be a result of pain and rising and c
A transverse uterine d) able to ambulate and do pulse rate, oxygen saturation and
anxiety position i
incision is used most often, daily activites with minimal temperature with each onset of
able to d
because it heals well and assistance pain
activities
there is less bleeding.  Walking promotes blood independen
Transverse uterine incisions flow of oxygen throughout going to
also increase the chance for the body while maintaining room
vaginal birth in a future  Assisted client to ambulate normal breathing comfortably
functions. Ambulation without an
pregnancy. However, the
stimulates circulation grimace
type of incision depends on
which can help stop the sleeping
the conditions of the
development of stroke- verbalized
mother and the fetus. causing blood clots. Walking relaxation e
improves blood flow which relieved pai
aids in quicker
wound healing.

SOURCE/S:

https://www.stanfordchil
drens.org/en/topic/defaul  If the client is well-rested .
t?id=cesarean-delivery- he/she often experiences
92-P07768 decreased pain and increased
Edx:
effectiveness of pain
management measures.
 Educated on energy-
conservation techniques such as
 Deep abdominal breathing
 encouraging client to take a lot
of rest
 Encouraged to do relexation
techniques like deep-breathing.
 Encouraged to increase the
consumption of foods high in
dietary iron such as malunggay,
spinach and liver. And also the
intake of foods high in folic acid
and vitamin B12 such as green
leafy vegetables and dairy
products.
 Instructed patient in ways to
monitor responses to activity
and significant signs/symptoms
that may indicate the need to
alter activity level.
 Advised to report promptly any
untoward feelings and concerns
about pain.
helps oxygenate blood which
triggers the release of
endorphins which decrease
release of stress hormones
and slows down heart rate.
 Packed red blood cells
increase oxygen-carrying
capacity of the blood thereby
reducing fatigue and
promoting healing and rest.s
 All these measures can help
the patient conserve energy
and reduce fatigue
 To ensure timely
intervention, prevent
complications and assist
client’s needs.
 Helps replenish the client’s
energy and also help cool
down body temperature,
decrease heart and
 respiratory rate

 Educated to drink plenty of

water every after onset of pain