NAME:OYARDO CHERILYN BED NO.

: 408
ATTENDING PHYSICIAN: DR.BALDOVINO DIET: DIET AS TOLERATED
DIAGNOSIS: POST-PARTUM
NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Acute vaginal pain After the 8 hours • Provide rapport • To gain trust and GOAL:
related to right span of my care the with the patient. full cooperation
“sumasakit yung PARTIALLY MET
medio lateral patient will be able during the pain
tahi
episiotomy as to express alleviation alleviation After the 8 hours span
paminsanminsan
evidence by facial of pain from pain procedures. of care the patient able
” as vervalized.
grimacing, guarding scale of 6 to 2. • Monitor vital • Vital signs altered to express alleviation
behavior. signs. during acute pain. of pain from pain scale
A. Will be able to
of 6 to 3.
OBJECTIVE: know different
techniques in A. GOAL MET
• Facial alleviation of • To aid in Able to know
grimace. pain. alleviation of different
• Pain scale • Provide a
B. Will pain. techniques in
of 6. therapeutic
comfortably alleviation of
environment.
• Slowed fall asleep. pain.
• Encourage
movement • To assist in B. GOAL MET
. verbalization of
evaluation. At the end of the
feelings.
shift the patient
• Encourage to do
able to sleep
diversional comfortably.
activities.
• Encourage rest • To alleviate pain.
and sleep

• To assess in
alleviation of
pain.
NAME: CULAWAY, IRENE BED NO.: P2
ATTENDING PHYSICIAN: DR.BALDOVINO DIET: DIET AS TOLERATED
DIAGNOSIS: POST-PARTUM
NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Acute pain related After the 8 hours • Establish rapport • To gain trust and GOAL: MET
“may lumalabas to childbirth pain span of my care the with the patient. cooperation. After the 8 hours span
pa pong dugo at characterized by patient will be able to • Establish NPI. • To assess the of my care the patient
minsan facial mask of pain express decreased • Monitor vital patient. express that the felt
sumasakit” as and diaphoresis. felt pain from pain signs. • Vital signs pain decrease to pain
verbalized. scale of 4 to 1. altered during scale of 1.
OBJECTIVE: A. Will be able to acute pain. A. Knew and able to
• Diaphoresis know and • Provide safety execute pain
• To avoid further
• Facial mask execute pain environment. alleviation
injuries.
of pain. alleviation • Encourage techniques.
• To assess the
• Pain scale techniques. verbalization of
condition of the
of 4 feelings.
patient.
• Encourage do
• To alleviate pain.
diversional
activities.
NAME: DEMETRIAL, VILMA BED NO.: P2
ATTENDING PHYSICIAN: DR.ETORMA DIET: DIET AS TOLERATED
DIAGNOSIS: POST-CS
NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Acute abdominal After the 8 hours • Provide rapport with • To gain full trust and GOAL: MET
“masakit parin ang pain related to span of my care the the patient. cooperation while
implementing pain After the 8 hours span
tahi sa akin” as post-CS injury as patient will be able to
alleviation of care the patient able
verbalized manifested by deal with the post- procedures.
to deal with the post-
OBJECTIVE: guarding behavior. operative pain. • To assess
operative pain.
• Guarding A. Will be able to • Monitor vital signs. abnormalities and
evaluation of Verbalized “nawa-wala
behavior know how to
conditions. wala na ang sakit”
• Slowed alleviate pain.
• To reduce further risk
ambulation. B. Will be able to of injuries. A. GOAL MET
• Diaphoresis. mobilize much • Provide hazard free Able to know
better with environment such as how to alleviate
safety. scattered things in the pain by
the floor.
practicing the
• Encourage • To assess the
condition of the
implemented
verbalization of
feelings. patient. activities.
• Encourage to do • To alleviate pain.
diversional activities. B. GOAL MET
• To aid in peristaltic Able to mobilize
• Advice to ambulate.
movement and
more frequently
elimination.
• To assist client and walks more
explore methods for often.
alleviation of pain.
• Instruct in use of
relaxation exercises
such as focused
breathing.
NAME: AGNO, MILDREDA BED NO.: 410
ATTENDING PHYSICIAN: DR.ETORMA DIET: CLEAR LIQUID DIET
DIAGNOSIS: POST-CS (1)
NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Acute post- After the span of my • Establish rapport • To gain full trust and GOAL: MET
“masakit yung operative pain 8 hours care the cooperation while After the 8 hours span
with the patient.
doing the procedure.
opera” as related to post- patient will be able to • Monitor vital of care the patient able
verbalized. cesarean injury as ambulate easily. • To aid in to ambulate.
signs.
OBJECTIVE: evidence by A. Will verbalized assessment and A. GOAL:
evaluation of
• Slow guarding behavior, the decreased PARTIALLY MET
facial grimace and felt pain from patient’s Verbalized
movement
slowed movement. pain scale of 5 • Establish NPI. condition. decreased felt
• Guarding
• To facilitate data
behavior to 2. pain from 5 to 3
gathering.
• Facial B. Will know how •
pain scale.
• Encourage To facilitate
grimace to execute assessment of B. GOAL: MET
verbalization of
methods of patients condition Knew and
feelings. and effectiveness of
alleviating executed the
• Encourage the implemented
pain. pain alleviation
diversional procedures.
methods.
activities. • To alleviate pain.
• Advice to
ambulate. • To aid in peristaltic
movement and
elimination.
• Encourage • To facilitate
relaxation and faster recovery
sleep. and alleviation of
pain.
NAME: NEGROSA, EMELOU BED NO.: 417
ATTENDING PHYSICIAN: DR.ETORMA DIET: DIET AS TOLERATED
DIAGNOSIS: POST-CS (6)
NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Acute post- After the span of my • Establish rapport • To gain full trust and GOAL: MET
“masakit ng di operative pain 8 hours care the cooperation while After the 8 hours span
with the patient.
doing the procedure.
gaano ang tahi” related to post- patient will be able to • Monitor vital of care the patient able
as verbalized. cesarean injury as ambulate easily. • To aid in to ambulate.
signs.
OBJECTIVE: evidence by A. Will verbalized assessment and A. GOAL:
evaluation of
• Slow guarding behavior, the decreased PARTIALLY MET
facial grimace and felt pain from patient’s Verbalized
movement
slowed movement. pain scale of 3 • Establish NPI. condition. decreased felt
• Guarding
• To facilitate data
behavior to 0. pain from 5 to 3
gathering.
• Facial B. Will practice •
pain scale.
• Encourage To facilitate
grimace methods of assessment of B. GOAL: PARTIALLY
verbalization of
alleviating patients condition MET
• Pain scale feelings.
pain. and effectiveness of Often practice
of 3 • Encourage the implemented
the pain
diversional procedures.
alleviation
activities. • To alleviate pain.
methods.
• Advice to
ambulate. • To aid in peristaltic
movement and
elimination.
• Encourage • To facilitate
relaxation and faster recovery
sleep. and alleviation of
pain.
NAME: EDRIGA, SWEET GRASHELA BED NO.: 416
ATTENDING PHYSICIAN: DR.ETORMA DIET: SOFT
DIAGNOSIS: POST-CS + BTL (2)
NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Acute post- After the span of my • Establish rapport • To gain full trust and GOAL: MET
“masakit yung operative pain 8 hours care the cooperation while After the 8 hours span
with the patient.
doing the procedure.
opera kapag related to post- patient will be able to • Monitor vital of care the patient able
gumagalaw” as cesarean injury as ambulate easily. • To aid in to ambulate.
signs.
verbalized. evidence by A. Will verbalized assessment and A. GOAL:MET
OBJECTIVE: guarding behavior, the decreased evaluation of Verbalized
patient’s
• Slow facial grimace and felt pain from decreased felt
slowed movement. pain scale of 6 • Establish NPI. condition. pain from 6 to 2
movement
• To facilitate data
• Guarding to 2. pain scale.
gathering.
behavior B. Will know how •
B. GOAL: MET
• Encourage To facilitate
• Facial to execute assessment of Knew and
verbalization of
grimace methods of patients condition executed the
feelings. and effectiveness of
alleviating pain alleviation
• Encourage the implemented
pain. methods.
diversional procedures.
activities. • To alleviate pain.
• Advice to
ambulate. • To aid in peristaltic
movement and
elimination.
• To facilitate
• Encourage
faster recovery
relaxation and and alleviation of
sleep. pain.
NAME: EDRIGA, SWEET GRASHELLA BED NO.: 416
ATTENDING PHYSICIAN: DR.ETORMA DIET: DIET AS TOLERATED
DIAGNOSIS: POST-CS + BTL (3)
NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING OF CARE IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Ineffective airway After the span of my • Provide rapport • To gain trust and GOAL: MET
“inuobo ako pero clearance related to 8 hours care the with the client. cooperation. After the 8 hours span
hindi naman retained secretions patient will be able to • Encourage deep- • To mobilize of care the patient able
lumalabas” as as manifested by mobilize secretion. breathing and secretion. to mobilize secretion.
verbalized. ineffective cough. A. Will know how coughing A. GOAL MET
OBJECTIVE: to execute exercise. • To open or Execute methods
• Ineffective methods of • Position head maintain patent of mobilizing
cough mobilizing midline with airway. secretions.
• restless secretions. flexion
appropriate for
condition
• To maintain
• Keep
airway.
environment
allergen free
according to
individual
situation. • To help liquefy
• Increase fluid secretions.
intake.