. Assessment S: Masakit and sugat ko paggumagalaw ako, as verbalized by the patient.

w/ a pain scale of 8/10 O: -Guarded and protective behavior -Facial grimace -Flushed skin - slow movement Nursing Diagnosis Acute Pain r/t surgical incision. Inference

= Nursing Care Plan for C/S = Objective After 1 of nursing intervention the pts pain will be lessened from pain scale of 8/10 to 2/10 Nursing Intervention Independent: 1. Note location surgical procedures 2. Perform pain assessment each time pain occurs. Note changes form previous reports. 3. Monitor vital signs 4. Provide comfort measures (e.g. back rub, change in position and relaxation exercises. 5. Provide quiet and calm environment. 6. Splint incision site when turning position or coughing. 7. Encourage adequate rest period. 8. Encourage diversional activities. Dependent: 9. Administer Ketorolac as ordered Rationale Evaluation Goal met, the patiens pain was reduced to 2/10

Pain receptors generate impulses Which are carried by special fibers in the peripheral nerves in by the lateral spinothalmic tract in the spinal cord and in the pain center in the hypothalamus.

1. This can influence the amount of postoperative pain experienced. 2. To rule out worsening of underlying condition or development of complications. 3. Usually altered with acute pain. 4. To provide nonpharmacologic pain management. 5. To avoid stimuli and to promote rest 6. To reduce pain at incision site 7. To prevent fatigue 8. To allay pts Attention from pain 9. To relieve pain

Assessment S di ako makagalaw ng maayos dahil sa sugat o As verbalized by the patient O- limited movements - Slow movement - looks weak

Nursing Diagnosis Altered Physical Mobility r/t surgical procedure (C/S)

Inference Caesarian Section delivery Surgical incision on abdomen Wound on the abdomen Pain is developed especially when moving Limited Mobility

Objective After 1 hour of nursing care, client will demonstrate techniques and behaviors that enable resumption of activities

Nursing Intervention Independent: 1. Monitor V/S 2. Assist Client with activities and provide use of assistive devices 3. Plan care between rest periods. 4. Instruct in use of side rails 5. Encourage adequate intake of fluids/ nutritious foods 6. Encourage expression of feelings

Rationale 1. To provide baseline data 2. To prevent injury 3. To reduce fatigue 4. For position changes/ transfers 5. Promotes well-being and maximizes energy production 6. To know the feelings of the patient, if she still has questions or clarifications.

Evaluation Goal met, the patient demonstrated techniques and behaviors that enable resumption of activities

Assessment O- Presence of Wound - Post surgical condtion

Nursing Diagnosis Risk for Infection r/t surgical incision

Inference Caesarian Section delivery Surgical incision on abdomen Wound on the abdomen Possibility for infection

Objective After the shift, the patient will be free from infection

Nursing Intervention Independent: 1. Monitor V/S 2. Provided a clean environment 3. Stress proper handwashing techniques to relatives, caregivers between therapies 4. Maintain sterility for invasive procedures 5. Change dressing as needed and indicated Dependent: 6. Administered amoxicillin as ordered

Rationale 1. 2.

Evaluation

3.

4. 5. 6.

Goal met, after the V/S is usually shift the patient was altered in an free form infection infection This will reduce the possibility of infection This will reduce the possibility of infection. Prevent infection To prevent risk of infection It is used for prophylaxis (prevention) of possible infection