Name: Jeelian D.

Rey
Year/Sec: Group 11D - BSN 2 – YA – 11
NURSING CARE PLAN

Assessment Nursing Background Planning Nursing Rationale Evaluation

Diagnosis Knowledge Intervention
Subjective: Acute Pain LTCS is the most After 1 week of 1. Monitor Vital ● To determine After 1 week of
“Hirap akong related to common type of nursing signs and risk for intensity or nursing
kumilos kasi surgical incision incision for interventions, the hypovolemia severity of pain interventions, the
sumasakit tahi and tissue cesarean section. patient will (Independent) and risk for goal is fully met, and
ko” as verbalized trauma (LTCS and It is on the lower report.  BP further risk of the patient is
by the patient. Appendectomy) part of the uterus  Prevent  Pain scale hypovolemia. relieved and not
as evidence by and extends from infection at  Temperatur ● To provide feeling any pain. As
Objective: pain scale of 8/10 side to side. A the surgical e optimal pain evidence by:
- Pain scale of at the incision side-to-side cut is sites. S/s: relief to the - Patient reports
8/10 site. made on the  Promote  Vomiting patient. manageable
- Pain where the lower part of the early  Constipation ● To avoid risk pain levels and
incision is made abdomen, making mobilization  Dehydration for infection demonstrates
it safer for VBAC. and physical  Gas pain since the understanding
VS: This means that activity. 2. Pain management patient need to of pain
T: 38.2 while a vertical  Reduced (Dependent) breastfeed her management
cut has more anxiety and - Administer baby. techniques. And
BP: 130/90 chances of provide ● Provide nursing abdominal band
prescribed
PR: 90 bpm breaking open psychological analgesics, parent is no longer
during the next support. antipyretic drug education to needed.
RR: 22 cpm pregnancy, a LSCS  Mother- (PARACETAMO aid - Incision sites are
lowers this risk by infant L: 500 mg/ IVT determining healing without
a huge bonding and every 8 hours) choice or signs of
percentage. This parenting. and antibiotic effectiveness of infection.
may be due to: (GENTAMICIN interventions. - Patient shows
Prolonged labor, 80mg/IVT every confidence in
fetal distress, 8 hours ANST) newborn care
fetal position, and and monitor and bonding
chances of effectiveness.
placenta previa. - Implement behaviors are
An non- evident.
appendectomy is pharmacologi - Patient shows
a surgical c pain relief hygiene and
procedure to measures proper changing
remove your (e.g., of wound
appendix. positioning, dressing.
Appendectomy is breathing
the standard exercises).
surgical - Educate the
treatment for patient about
appendicitis, a pain
painful management
inflammation of strategies.
the appendix. 3. Infection
Because an Prevention
inflamed (Independent)
appendix has the - Maintain
potential to aseptic
rupture, technique
appendicitis is during
considered a dressing
medical changes.
emergency. A - Monitor
ruptured incision sites
appendix can be for signs of
very dangerous. infection
(redness,
swelling,
drainage).
- Educate the
patient on
signs of
infection
 and wound
care.
4. Parenting support
(Independent)
- Facilitate
skin-to-skin
contact and
breastfeedin
g as soon as
possible
post-
surgery.
- Educate on
newborn
care and
involve the
partner in
caregiving.
- Monitor for
postpartum
depression
and provide
referrals if
needed.
5. Wound Care
(Independent)
- Educate the
patient
proper
wound care
to avoid
getting the
wound
infected
- Perform
proper
hygiene
- Cleaning the
surface area
of the
wound to
avoid
infection.