NURSING CARE PLAN OF

ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
Subjective: patient Acute pain Independent  Established rapport To have good Goal met.
says that she is related to After 2-3 hours  Eatablish rapport. by taklking normal nurse patient After 2hrs of
having pain around disruption of of nursing thing as well as relationship. nursing
the abdominal area skin and tissue intervention, telling her about intervention,
patient will condition being
secondary to the patient
verbalize friendly behavior.
cesarean verbalized
decrease
section. intensity of pain pain
Objective: from 8/10 to  Monitor vital sign  Monitored vital sign To establish decreased
-pain scale 8/10,tery 3/10. BP 110/80 baseline data. Evidenced by
eyes,facial grimace P= 80/m (-) facial
positive,irritable,skin RR22/m,T=37.6 grimace
warm to touch (-) guarding
 Assess behavior.
quality,characteristi Assessed quality, To establish
c, severity of pain. characteristic, severity baseline data for
of pain. That is when comparison in
change the position and evaluation and to
during coughing it assess for possible
incread. internal bleeding.

 Provide comfortable  Provided Calm environment

environment comfortable helps to decrease
environment – the anxiety of
changed bed linens patient.
and turned on the
fan.
 Instructed to put To check for
 Instruct to put pillow on the diastasis recti and
 pillow on the abdomen when protect the area of
abdomen when coughing or moving the incision to
coughing or moving improve comfort.

 Instruct patient to  Instructed patient For pulmonary

do deep breathing to do deep ventilation.
and coughing breathing and
exercise coughing exercise

 Provide diversionary  Provided To promote

activities diversonary circulation,
activities. Initiate prevent venous
ankle pumping, stasis; prevent
active lower pressure on the
extremity ROM, and operative site.
walking

Collaborative
-administer analgesic as  Administered Relieves pain felt
per doctor’s order. analgesic as per by the patient.
doctor’s order
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective Ineffective The mother To teach the Mother was educated on feeding The mother
data: breastfeeding will feed the mother schedule Feeding on demand and verbalized the
Subjective related to infant feeding 1. She was advised to feed the every 2 hourly helps the importance of
The mother position, successfully schedule. new born on the demand from breast to be emptied breast feeding
complains condition of and will have the baby and every 2 hours is avoiding breast on demand
that the baby nipples, and a sense of desirable. complication. and how it
cannot feed infant's satisfaction would be able
well since sucking ability with 2. She was educated that each to help in
she has no breastfeeding breast should be allowed to feed making of
milk and that process for 20 minutes with greatest more milk and
it’s painful quantity of milk consumed in first preventing
for her when The baby will 5 to 10 minutes. breast
the baby is be feed on complications.
feeding on both breasts Mother was educated on Good breastfeeding
her breast. successfully. breastfeeding techniques. techniques will be able Mother was
Mother was a. Mother and infant in to attach the baby able to
Objective educated on comfortable position, such as semi properly to breast and verbalize the
The mother breastfeedin reclining or in comfortable side hence the baby will feed importance of
was not able g techniques. lying position well on breast which breast feeding
to position would again prevent techniques
the baby well . Entire body of infant should be breast complications. and different
on breast. turned toward mother's breast; techniques.
alternate starting breast and use
both breasts at each feeding She was able
. to
The mother Initiate feeding by stimulating demonstrate
verbalized rooting reflex and direct nipple the techniques
that she had straight into baby's mouth well.
pain while (stroking cheek toward breast,
feeding her being careful not to stroke other The mother
baby. cheek, because this will confuse very well
infant) Burping the infant burped the
The nipples allows the air to baby by
were tender . Burp or bubble infant during and escape and placing him on
and mild after feeding to allow for escape prevent her lap and
cracks of air. regurgitation patting gently
present

The mother
To teach The mother was educated on was cleaning
mother care breast care: Cleaning with soap will the nipples
of breast. a. Cleanse with plain water once make the nipples drier only with
daily (soap or alcohol can cause and more prone to water and
irritation and dryness cracks. applied
Colostrum
. Support breasts day and night prior to
with properly fitting brassiere Properly fitting bra feeding to
supports the lubricate the
Nursing pads should be placed breast well nipples.
inside bra cup to absorb any milk
leaking between feedings; allow This allows absorption Mother was
nipples to air dry at intervals of the milk into the pads using well
and prevents clogging of supporting bra
nipples.
Mother had no
If breasts are engorged, teach Warm showers and breast
mother to take warm showers and breast feeding relieves engorgement
put baby to breast more breast tenderness and
frequently engorgement
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Risk for infection Independent
none related to Short term goal -monitor vital signs - monitored vital signs To established
inadequate After 3 hours of T=37.3 baseline data.
primary defenses nursing P=80
secondary to intervention, R=19
Objective: surgical incision. patient will be BP=120/80
-dressing dry able to
and intact understand - inspected dressing it
-inspect dressing and -moist from drainage
- vital sign causative was dry and perform
perform wound care can be a source of
taken as factors, identify wound care by applying
infection.
signs of infection antiseptic solution
follows:
butadiene..
T=37.3 and report them
P=80 to health care -monitor white blood
- monitored white blood
R=19 provider count(WBC) Rising WBC indicates
count(WBC) it was
BP=120/80 accordingly. body’s efforts to
normal range of
combact pathogens.
6000mm3
-Monitor elevated
Long term goal - Monitored elevated
temperature, redness, -these are signs of
After 2-3 days of temperature, redness,
swelling increased pain, infection.
nursing swelling increased pain,
or purulent drainage at
intervention, or purulent drainage at
incision site.
patient will incision site, no
significant changes.
achieve timely
wound healing, Fluids promote
-encourage fluid intake. - encourage fluid intake
be free of diluted urine and
(unless contraindicated) of 2000 ml to 3000 ml
purulent water per day frequent emptying
drainage, be of bladder,
afebrile and be reducing stasis of
free of infection. urine, reduces risk
 of bladder infection
or urinary tract
infection (UTI).
-encourage coughing and - encouraged coughing
These measures
deep breathing, consider and deep breathing,
reduce stasis of
use of incentive consider use of incentive
spirometer. spirometer secretions in the
lungs and bronchial
tree.
-administer antibiotics - administered antibiotics
inj amplox 500 TDS as Bactericidal effect
prescribed by doctor. that combacts
pathogens.
 Day 2

ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
Risk for Short term goal After 6 hour
Objective: constipation Within 6 hours of  Auscultate for  Auscultate done Evaluates nursing
patient has related to post nursing presence of bowel for presence of bowelfunction, interventions,
not yet pregnancy interventions, the sounds, palpate for bowel sounds, identifies deviation the patient
patient will be diastasis recti, and palpate for from client’s
eliminated cesarean section. was able to
able to
since determine normal diastasis recti, and normal or usual identify
domenstrate
delivery evacuation habits. determine normal routine measures to
behaviors or
lifestyle changes evacuation habits. prevent
Normal to prevent infection as
pattern of developing  Provide dietary manifested by
bowel has problem. information  Provided dietary Roughage and patient’s
not yet regarding information increased fluids verbalization .
returned Long term goal importance of regarding provides bulk,
roughage, importance of improve
Within 3 days of increased fluids, roughage, consistency of
nursing stool, and stimulate
and the attempt to increased fluids,
interventions, the
establish normal and the attempt to elimination
patient will be
able to maintain evacuation pattern establish normal
usual pattern of evacuation pattern
bowel functioning.
 Encourage fluid  Encouraged fluid Assist in improving
intake intake of 2500 – stool consistency
3000 ml/day within
cardiac tolerence
 Recommending
avoiding gas  Recommended Decrease gastric
forming foods avoiding gas distress and
forming foods like abdominal
 cabage,green distention
piesce etc.

 Encourage  Encourage To stimulate

ambulation ambulation such as contractions of the
walking within intestines and
collaborative individual limits prevent post
operative
complications.

 Administer stool  Administered stool Facilitates

softners, softners enema defication when
suppositories, andlaxatives as constipation is
enema or laxatives indicated present
as indicated
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective Altered parent To establish .
Woman baby bonding To establish family Encourage client to hold, touch The first hour Demonstrates
verbalizes attachment between unity and bonding. and examine the baby and assist after delivery appropriate
that she related to parents and the mother as needed. offer unique bonding and
cannot hold physical newborn To develop opportunity for relationship,
the baby and complication positive appraisal family bonding to by touching
feed since interfering with for birth and occur because baby and
she has pain. initial assume both mother and talking to him.
acquaintance as infant are
Objective evidenced by emotionally
The mother hesitancy to receptive to cues
refuses to hold the baby. from each other Mother was
hold the Allow parents the opportunity taking about
baby in her to verbalize negative her increased
arms and responsibilities
looks Unresolved at home.
irritated. conflicts during
the early parent-
infant feelings
about themselves Breast feeding
and the infant. Enhances child
Early contact has mother
a positive effect bonding and
on duration of on relationship.
client’s choice
and cultural.
Encourage and assist with Breast feeding is
breastfeeding, dependent the best bonding
beliefs/practices.breastfeedings; technique
skin-to-skin contact and
initiation of maternal tasks
promotes bonding.
S.N DRUG ROUTE/ ACTION SIDEEFFECTS Contra NURSING RESPONSIBILTY
o FREQUENC indication
Y
1. Inj ceftriaxone I/V 12 Inhibit bacterial cell Headache, Hypersensitivity Assess
hourly wallsynthesis,rendering dizziness,,weakness,,fe to -sensitivity to penicillin, other
cell wall osmotically ver, chills, seizures, cephalosporins, cephalosporine,
unstable,leading to cell nausea,vomiting, infants less than -urine output: if decreasing,
death. diarrhea, abdominal 1 month. notify prescriber,may indicate
pain,proteinurea. nephrotoxicity.
- electrolote: if patient is on
long- term theraphy
-bowel pattern daily, if severe
diarrhea occur,
- I/V site for extravasation,
phlebitis.

2. Inj Aciloc 50 mg, 8 Antiulcer action, aciloc Malasia , vertigo, Hypersensitivity

hourly competitively inhibits bullered to ranitidine HCL -Instruct patient to take drug
histamines action at h2 vision,pancytopenia, as directed, even after pain
receptors in gastric granulocytopenia, subside to ensure proper
parietal cell. thrombocytopenia healing.
- drug is excreated in breast
milk, use cautiously in breast
feeding women.
- tell patient to swallow oral
Severe renal medication whole with water
disease, do not.
3. Inj Gentamycin 80 mg, BD Interferes with protein Confusion ,depression, hypersensitivity,
synthesis in bacterial numbness, tremors,
cell by binding to seizures, muscle -Weight before treatment
ribosomal subunit, twitching, dizziness, -Maintaining I/O chart.
 causing misreading of vertigo,visual -watch for hypotension,
genetic code, disturbance, nausea change in pulse.
inaccurate peptide ,vomiting,proteinuria. - I/V site for
sequence forms in thrombophlebitis, including
protein chain, causing pain, redness, swelling, apply
bacterial death. warm compress to site.
Pregnancy 1st
trimester,
4. Inj metron 100ml, 8 Direct acting Headache breastfeeding,
hourly amebicide/trichomona ,dizziness,confusion,,irr hypersensitivity
cide binds, disrupt DNA itability,restlessness, to this product, Assess
structure inhibiting ataxia,depression,draw CNS -For infection- WBC, wound
bacterial nucleic acid siness, disorders,GIdisea symptoms, fever, skin or
synthesis. insomnia,scizures,blurr se. vaginal secretion
ed vision,darkened -For opportunistic
urine, libido fungalinfections
-Maintain I/O chart, weight
daily, stool for number,
frequency,character.
. -do not break, crush or chew
ER products.
-po with after meal to avoid
GI symptoms.
Children under 6
years,pregnancy(
5. Inj voveran 75 mg, sos Diclofenac is potent Headache, nausea , 3rd trimester
anti- inflammatory, vommiting ),lactation,bronc
analgesic and hial - Check the vital signs
antipyretic action asthma,urticaria. - Check the 7 rights of
medication.