NURSING CARE PLAN #1

Assessment Diagnosis Planning Implementation Rationale Evaluation

(NANDA- based)

Subjective: Acute pain related to Short term: Independent: Short term:

abdominal incision
“Sakit pa akong tahi” secondary to cesarean After 2-3 hours of a) Provided a) To provide >Patient
verbalized by the nursing intervention, conducive adequate rest demonstrated
section
patient the patient will be able environment such b) To reduce intra participation by
as providing quite abdominal
to: positioning herself in a
>Pain score of 6 out surrounding and pressure
minimal c) To help alleviate comfortable position
of 10, 10 as the a) Verbalized that and by doing the
pain is decrease stimulation pain
highest score advised regimen
from 6 to 3 out of b) Encouraged to d.) To divert patient
10 pain score assume attention for pain
comfortable >Pain score
b) Demonstrates
Objective: participation in position decreased to 3 out of
therapy c) Assisted with deep 10 pain score
>Facial grimacing breathing
d) Provided
upon moving
Long term: diversional
activities and Longterm:
> Frequent massaging
After 8 hours of assisted in
of affected area relaxation >Verbalized
nursing intervention,
techniques such understanding of the
> refusal to sit due to the patient will be able as socialization whole regimen
pain on site to: and guided Collaborative:
imagery > verbalized control of
a) Report pain is e.) help relieve pain
relieved or pain by slowly sitting
Collaborative:
controlled on her own
e.) Administer
Tramadol,1cap(50mg)
TID,PO as ordered by
the physician

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 NURSING CARE PLAN #2

Assessment Diagnosis Planning Implementation Rationale Evaluation

(NANDA- based)

Subjective: Short term: Independent: Short term:

a.) To prevent
“sakit akong tahi Impaired skin After 4 hours of nursing a.) Encourage infection >demonstrated
sa tiyan” integrity related to intervention, the patient frequent behaviors in
verbalized by Surgical Incision will be able to: proper wound b.) To relieve promotion of
care and pressure on
patient a.) Verbalizing healing and
dressing affected area
willingness to prevention of
and promote
cooperate b.) Instruct comfort complications as
b.) Exercises patient on manifested by:
frequent proper proper c.) To limit
wound care. positioning metabolic 1. Verbalizating
c.) Demonstrates demands, her own
Objective: proper c.) Encourage maximize understanding
positioning and adequate rest energy of condition and
>Cesarean incision early mobility periods available for causative
in the lower healing, and factors
transverse part of d.) Emphasize meet comfort 2. Verbalized
Long term: willingness to
abdomen need for needs
adequate d.) To optimize cooperate
After 8 hours of nursing
>wound dressing nutritional and healing 3. Exercised
intervention, the patient
fluid intake potential frequent proper
will be able to: wound care
e.) Encourage e.) Promotes 4. Demonstrated
d.) clean, dry and
early mobility circulation proper
intact wound site
which positioning and
e.) Display
facilitates early mobility
progressive
improvement in healing and
wound or lesion prevent
healing excessive

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 tissue Long term:
pressure
Collaborative > Maintained clean,
/Depentent: dry, absent edema
Collaborative and intact incision
f.) Administer site
medication as f.) To decrease
ordered discomfort
and improve
g.) Discuss circulation in
importance of the area
early
detection and g.) To prevent
reporting of infection and
changes in facilitate
condition or healing
any unusual a.) Promotes
physical early
discomforts or intervention
changes in and reduces
pain
characteristics potential for
complication
ns

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 NURSING CARE PLAN #3

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Short term: Independent:

Patient Grieving After 4 hours of nursing a.) Provided open a.) Promotes a free Short-term:
verbalized: related to interventions, the environment and discussion of >Slowly
“Wala naman loss of child patient will be able to: trusting relationships feelings and expressed
feelings
jud siya, saying with significant concerns
a.) Express feelings regarding
lagi pero wala others and other situation
na siya.” freely support persons >Verbalized
b.) Acknowledge
b.) Provides support to words that
situation b.) Provided therapeutic demonstrates
client
communication skill acknowledgment
Objective: Long term:
such as silent
>Watery eyes At the end of 8 hours Long term:
listening and c.) Lessens sense of >Verbalized
upon of nursing acknowledgement of guilt and affirms understanding of
expressing interventions, the patient expression there’s no need to the nursing care
feelings patient is expected to: of feelings blame self or any given
>Shows little a.) Accept reality of family member
c.) Provided assurance
avoidance in situation
b.) Demonstrate that the cause of d.) Encourages family
discussing
activities of self- situation is not support and assist
situation
care client’s own doing client to deal with
>Sometimes c.) Look towards
situation
and plan for
appears to be
future one day
detached and d.) Incorporated e.) Promotes positive
at a time
inattentive supporting others in outlook
problem-solving

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 e.) Discussed and
assisted in planning
for future plans,
such as finishing Collaborative/Dependent:
education

Collaborative/Dependent: f.) For support and to

f.) Encouraged to have help face current
or to avail situation by the
counseling in Brgy. advices of the
Health Center professional

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 NURSING CARE PLAN #4

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Short term: Independent: a.) A first line of defense Short term

against health care
Subjective: Risk for At the end of 1-2 a.) Encouraged proper associated infections >Actively
infection related hours of nursing hand hygiene by all b.) To reduce bacterial participated to
Patient to surgical interventions, the caregivers between colonization achieve goals of
verbalized: therapies and clients care
incision patient will be able
“sakit akong tahi to: c.) For mobilization of >Identify
sa tiyan b.) Recommend routine
body shower or scrubs respiratory secretions interventions to
a.) Actively
and preventions of prevent reduce
participate to
respiratory infection risk of infection
achieve goals of
care c.) Encouraged early
ambulation, deep d.) To void bladder for
breathing, coughing distention and urinary Long term
b.) Identify
interventions to and position changes stasis
Objective: >Showed no
prevent or signs of infection
>Surgical reduce risk of
incision in low infection d.) Maintain adequate
hydration, stand or sit e.) To boost immune
transverse
to void, and system.
abdomen Long term: catheterized if
>WBC: necessary.
At the end of 6-8
10.33X10^12/L
HIGH hours of nursing
interventions, the e.) Encouraged to eat
patient is foods rich in Vitamin C.

expected to:

a.) Show no signs of

infection

33
 Collaborative/Dependent

Collaborative/Dependent f.) To evaluate treatment

f.) Collaborate with doctor

and lab technician to
continue monitoring
patients WBC count.

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 NURSING CARE PLAN #5

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Readiness for Short term: Independent: Short term:

enhanced
Patient coping At the end of 1-2 hours a.) Actively listened a.) To understand >Identified
verbalized: of nursing and clarified perception of possible coping
“Wala na siya interventions, the patient’s perception patient in relation to methods
pero unsaon patient will be able to: of current status reality for further
taman, basin dili planning of care >Demonstrated
palang jud a.) Identifies participation in
karon ang effective coping b.) Enable client to nursing
panahon para behaviors identify successful interventions
sa amo. Iampo b.) Demonstrate b.) Discussed ways of techniques to
na lang namo.” coping attitude handling situation promote feelings of
which is that is more confidence Long term:
Objective: congruent with convenient or easy
behavior for the patient >Identify
possible ways
At the end of 8 hours – c.) Enhance coping
of coping with
3 weeks of nursing skills and
the situation
interventions, the strengthen client’s
patient is expected to: ability to manage
c.) Encouraged patient challenging
a.) Meet to create stress situations
psychological management
needs program

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 d.) Promote relaxation
and diversional
activities

d.) Recommended
involvement of
activities of interests e.) Promotes
such as exerices, relationship of
sports, music, and client with
arts significant others
and provides
activities that are
more personal to
e.) Included significant client and more
others in planning meaningful
for coping activities
Collaborative/Dependent
for client
f.) Supporting others
also grieve and
Collaborative/Dependent they are the
primary supporting;
f.) Including family in holistic care from
the care patient to family
g.) Asked peer groups g.) For more support
or other close and also a way of
related person to diversional activity
support

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