NURSING CARE PLAN NO.

Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation

Impaired breathing Within 8 hours of
Subjective: pattern related to pain nursing intervention, Goat met!
“ nag lisod kog ginhawa as evidenced by the patient will be able 1. Monitor the patient’s 1. Regular monitoring After 8 hours of nursing
kay tungod sakit akong tachypnea to, maintain a stable respiratory rate, rhythm of the respiratory rate intervention the patient
tahi” respiratory rate within a , and depth regularly. is essential to assess maintain the normal
Objective: normal range for their the severity of rapid respiratory rate with the
- Tachypnea age and condition 2. Encourage the patient breathing and to track use of
- RR of 28 to exercise deep any changes over nonpharmacological
- Patient's breathing to enhance time. technique such as deep
respiratory rate, lung expansion and breathing exercises and
rhythm, and depth maintain respiratory 2. Deep breathing proper and pursed lips
of breathing are depth. exercises can help breathing.
abnormal. improve lung
3. Ensure that the patient's expansion and
Vital signs are as airway is clear and respiratory depth,
follows: patent. Suction if potentially reducing
Bp: 130/80 mmHg necessary to remove the respiratory rate.
Temp: 36.5 c any obstructions.
RR: 28 CPM 3. A clear and patent
HR- 86 bpm 4. If the patient is in airway is necessary to
PR- 95 bpm respiratory distress, facilitate effective
offer support with their breathing.
breathing. Encourage
slow, deep breaths and 4.When the patient
relaxation techniques. is in respiratory
distress, supporting
5. Anxiety and stress their breathing with
can exacerbate slow, deep breaths
 rapid breathing. and relaxation
Provide reassurance techniques can help
and a calm, alleviate the rapid
supportive breathing pattern
environment. and reduce anxiety.

6. Identify and address 5. Providing

the underlying reassurance and a
cause of rapid calm, supportive
breathing. environment can
help relax the
patient and reduce
7. Continuously respiratory distress.
monitor the
patient's respiratory
rate, oxygen 6. Addressing the
saturation, and underlying
overall condition condition, such as
asthma or
8. Provide infection, is
reassurance and a calm, essential for
supportive effective
environment. management.

9. If the rapid 7. Continuous

breathing is due monitoring of the
to an underlying patient's respiratory
medical rate, oxygen
condition such saturation, and
as asthma or a overall condition is
respiratory necessary to assess
infection, interventions'
administer effectiveness and
 prescribed make real-time
medications adjustments to
(e.g., care.
bronchodilator
s, antipyretics,
or antibiotics) 8. A reassuring and
as directed by supportive
the healthcare environment can
provider. help alleviate
anxiety and stress,
10. Work closely with which may
physicians, respiratory contribute to rapid
therapists, and other breathing.
healthcare
professionals to ensure 9. These medications
appropriate address the specific
interventions and cause of the issue.
management of the
underlying condition.
10. Collaboration with
physicians, respiratory
therapists, and other
healthcare
professionals ensures
that the patient
receives
comprehensive care
and that the
underlying condition
is appropriately
managed.
 NURSING CARE PLAN NO. 2
Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation
Subjective: Acute pain related to Within 8 hours of
“ sakit akong tiyan post-operative procedure nursing intervention, 1. Regularly assess the Goat met! The patient
tungod sa samad nako sa as evidenced by surgical the client will patient's pain using a pain scale 1. It helps in tailoring verbalize that her pain
tiyan’ incision verbalize the the care plan to the scale is 4 out of 10 and
Pain scale 7 out of 10 reduction of pain 2. Offer comfort measures patient's unique needs. ensure the patient’s
intensity. such as warm blankets, comfort. She is able to
soothing music, dimmed 2. Creating a soothing manage her pain
Objective: lighting, and a calm environment reduces effectively and cope with
- Guarding environment to reduce anxiety anxiety, which can pain using
behavior and promote relaxation. exacerbate pain pharmacological method.
- Irritable perception. The patient is also engage
Vital signs as follows: 3. Apply cold or warm in breathing exercises and
Bp: 130/80 mmHg compresses to the surgical site, 3. Provide localized uses her phone to divert
Temp: 36.5 c per physician's orders or relief by reducing her attention away from
RR: 28 CPM patient preference. inflammation and the pain.
HR- 86 bpm improving blood flow
PR- 95 bpm 4. Offer activities or to the area.
diversional therapy to help
divert the patient's attention 4. Distraction
away from the pain, such as techniques divert the
reading, watching TV, or patient's attention
engaging in hobbies. from pain, helping
them cope with
5. Ensure proper care of the discomfort more
surgical incision site to prevent effectively.
infection or complications.
Provide guidance on dressing 5. Proper wound care
changes and signs of infection. is crucial for
6. Regularly assess the preventing
effectiveness of the complications,
interventions and make reducing the risk of
necessary adjustments to the infection, and
pain management plan based ensuring the surgical
on the patient's response incision heals
properly.

7. Administer prescribed pain 6. Regular evaluation

medications as ordered by the helps determine the
physician and ensure the effectiveness of
patient receives them on time interventions,
to maintain pain control. allowing adjustments
-Paracetamol 500mg for 1 to the pain
dose via low as IV push then management plan to
after 6 hours achieve better pain
relief and overall
patient comfort.
8. Educate the patient on the
importance of adhering to the 8. Administering
pain management plan, pain
including the timing and medications as
dosages of pain medications prescribed by
the physician is
9. Instruct the patient in deep essential for
breathing exercises and pain control
relaxation techniques to reduce and promoting
muscle tension and improve the patient's
oxygenation. comfort.
 10. Communicate any changes 9. Patient
in the patient's pain status or education
adverse effects of pain ensures that the
medications to the healthcare patient
team for appropriate understands
adjustments. their pain
management
plan. Helping
the patient cope
with pain more
effectively.

10. Effective
communication with
the healthcare team
ensures that any
changes in the
patient's condition or
adverse effects of
medications are
addressed promptly.

NURSING CARE PLAN NO. 3

Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation

Subjective: Constipation related
“ Wala pako kalibang to impaired physical Within 8 hours of
sukad nanganak ko” mobility as evidenced nursing intervention, 1. Provide information 1. A balanced diet Goal met!After 8 hours
Objective : by a post-operative the patient will be able on how to maintain and regular of nursing intervention,
- Bloated procedure. to have a successful a healthy diet, stay exercise promote the patient have a
- Post-operative bowel movement and hydrated, and bowel regularity, successful bowel
patient with alleviate constipation engage in regular and hydration movement, alleviate
surgical site exercise. softens stool. constipation with rich in
incision fiber foods , drinking
- With surgical 2. Suggest smaller, 2. Smaller, frequent water , and promote
dressing on below more frequent meals are easier to gastrointestinal comfort
the umbilicus. meals and snacks to digest and can help while maintaining surgical
- support caloric maintain energy recovery and physical
Vital signs as follows: intake, especially if and caloric intake mobility.
Bp: 130/80 mmHg the patient's even when the
Temp: 36.5 c appetite is reduced. appetite is reduced.
RR: 28 CPM
HR- 86 bpm
PR- 95 bpm 3. Ensure that the patient 3. This intervention
has a private and comfortable helps create a
environment for toileting, relaxed atmosphere
which can help reduce stress for toileting.
and anxiety that might
exacerbate constipation. 4. Patient education
on the significance
4. Educate the patient about the of regular bowel
importance of regular bowel movements
movements and the factors encourages them to
contributing to constipation. actively participate
in relieving
5. Monitor for signs of constipation.
discomfort, abdominal
distension, or other symptoms 5. Regular monitoring
related to constipation. for signs of
discomfort,
6. Provide education on the abdominal
benefits of a high-fiber diet for distension, or other
preventing constipation. symptoms is
crucial to identify
7. If prescribed by the constipation
healthcare provider, administer promptly and
stool softeners or laxatives to initiate
relieve constipation and interventions.
encourage regular bowel
movements. 6. Educating the
patient about the
8. Continuously assess the benefits of a high-
patient's progress in relieving fiber diet reinforces
constipation and achieving a the importance of
regular bowel pattern. Adjust dietary choices that
the plan as needed based on the prevent
patient's response. constipation.

9. Encourage gentle physical 7. Administering

activity, such as walking, as prescribed stool
soon as it is safe and softeners or
comfortable for the patient laxatives, under the
post-cesarean section. direction of a
healthcare
provider, is
10. Work in collaboration with necessary to
other healthcare professionals, provide
including obstetricians, to symptomatic relief
ensure that interventions do not from constipation
interfere with the patient's and facilitate
postoperative care. regular bowel
 movements.

8. Continuous
assessment of the
patient's progress is
essential to
determine the
effectiveness of
interventions and
make necessary
adjustments to the
care plan.

9. It is important to
consider safety and
patient comfort in
post-cesarean care.

10. This coordination

of care provides a
holistic approach to
the patient's well-
being.

NURSING CARE PLAN NO. 4

Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation

 Subjective Self-care deficit related Within 8 hours of
“Pag mag cr ko naa dapat to surgical procedure nursing intervention, 1. Conduct an initial 1. The initial pain Goal met! After 8 hours
akong bana or akong and impaired physical the patient will be able pain assessment to assessment is of nursing intervention,
manghud para ubanan ko mobility as evidenced to improve determine the level of crucial to the patient is be able to
inig mag cr ko” by difficulty accessing independence in discomfort understanding the improve her independence
the bathroom performing self- care experienced by the patient's pain level in performing self- care
Objective: activities patient. and tailoring pain activities, including safety
- Post-operative management accessing the bathroom
patient with 2. Educate the patient interventions to with minimal or no
surgical site and caregivers on the their needs. assistance , enhancing
incision correct usage of these overall self- care and
- With surgical devices to ensure 2. Proper education physical mobility.
dressing on below safety and comfort on the use of
the umbilicus during toileting. assistive devices
Vital signs as follows: ensures the patient
Bp: 130/80 mmHg and caregivers can
Temp: 36.5 c 3. Develop and adhere to use these devices
RR: 28 CPM a toileting schedule safely and
HR- 86 bpm for the patient within effectively,
PR- 95 bpm the 8-hour shift to reducing the risk of
ensure timely and accidents and
consistent assistance. promoting comfort.

4. Assess the patient's 3. A toileting

environment for schedule ensures
potential safety that the patient
hazards and address receives timely
them to minimize the assistance,
risk of falls or reducing
accidents. discomfort and the
risk of accidents.
5. Continuously reassess
the patient's comfort, 4. Assessing the
 pain levels, and patient's
toileting needs environment for
throughout the shift safety hazards
helps create a safer
6. Encourage the patient toileting
to communicate any environment,
discomfort or need for minimizing the risk
assistance promptly of falls and
accidents.
7. Provide and assist the
patient in using 5. Continuous
appropriate assistive reassessment of the
devices for toileting, patient's comfort,
such as a raised toilet and toileting needs
seat, commode chair, allows for real-time
or grab bars. adjustments to
interventions,
8. Ensure that the patient ensuring the
is assisted to the bathroom patient's well-
or commode at regular being.
intervals based on their
needs and the healthcare
provider's 6. Effective
recommendations. communication and
responsiveness to the
9. Educate the patient and patient's needs contribute
caregivers on the correct to a positive nurse-patient
usage of these devices to relationship. It fosters trust
ensure safety and comfort and a sense of partnership
during toileting. in care.
10. 7. Providing and
Provide brief education to assisting the patient with
the patient and caregivers the use of assistive devices
on the importance of enhances safety and
proper body mechanics comfort during toileting.
during toileting to reduce
pain and ensure safety. 8. Assisting the
patient to the
bathroom or
commode at
regular intervals,
based on their
needs and
recommendations,
ensures that their
toileting needs are
met promptly.

9. Education with
caregivers on the
correct usage of
assistive devices
ensures that the
patient receives
consistent support
and maintains
safety during
toileting.

10. Education on proper

body mechanics reduces
the risk of injury and pain
during toileting, promoting
safety and comfort.
 NURSING CARE PLAN NO. 5

Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation

Decreased activity Within 8 hours of
Subjective: tolerance related to nursing intervention,
“ Mag lisod kog lihol post-operative the patient will 1. Instruct patient in a Goal met!. After 8 hours
lihok kay sakit akong procedure as evidenced experience reduced range of motion 1. These exercises of nursing intervention,
samad” by exertional exertional discomfort exercises to prevent also help reduce the patient experience
Objective: discomfort. and an improved ability joint contractures muscle stiffness reduced exertional
- Restlessness to engage in activities and discomfort. discomfort and an
- Unable to stand with increased 2. Conduct a thorough improved ability to
- Slow and limited tolerance and comfort. assessment to 2. A comprehensive engage in activities with
movements. determine the patient’s assessment of the increased tolerance and
- With surgical current mobility status, patient's mobility comfort. With the
dressing on below including range of status provides a respiratory rate of 95%
the umbilicus. motion, muscle baseline for care during and after. She is
strength, and any pain planning and helps able to manage pain with
Vital signs as follows: or discomfort identify any pharmacological method,
Bp: 130/80 mmHg limitations or assisting the patient in
Temp: 36.5 c issues that may changing position, getting
RR: 28 CPM 3. Assist patient with require in and out of the bed and
HR- 86 bpm mobility and self-care intervention. she is able to put the
PR- 95 bpm activities, providing abdominal binder in her
necessary support as 3. Gradual stomach.
needed. progression helps
the patient regain
4. Ensure that the patient strength and
knows how to safely confidence.
transfer from the bed to
 a chair or from a seated 4. Teaching safe
to a standing position transfer techniques
is crucial to
prevent falls and
5. Promote a balanced injuries during
approach to avoid transfers,
excessive fatigue and especially for
support recovery patients with
mobility issues.

6. Teach the patient 5. It is essential to

proper techniques for maintain a healthy
moving in bed, activity level
including turning and while allowing
repositioning to prevent time for rest and
pressure ulcers and recuperation.
discomfort.

7. Implement fall 6. Educating the

prevention measures, patient about
such as bed alarms, proper body
non-slip socks, or a positioning and
bedside commode, if repositioning
necessary to minimize reduces the risk of
the risk of falls. skin breakdown.

8. Teach the patient and 7. Bed alarms, non-

caregivers proper body slip socks, and
mechanics when bedside commodes
moving and lifting to help reduce the
prevent injury and risk of falls.
strain.
 9. Administer 8. Ensuring that the
Paracetamol 500mg patient and
for 1 dose via low as caregivers use
IV push then after 6 proper body
hours before the mechanics during
activity to help movement and
alleviate exertional lifting reduces the
discomfort risk of injury and
strain on muscles
10. Work with the and joints.
healthcare team,
including the physical 9. To alleviate the
therapist and patient pain before
occupational therapist, doing the
to develop and interventions
implement a
comprehensive plan for
enhancing mobility 10.Working with
physical therapists and
occupational
therapists ensures a
comprehensive
approach to enhancing
mobility.

NURSING CARE PLAN NO. 6

Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation

Subjective: Disturbed sleep Within 8 hours of
“ Putol putol akong tulog pattern related to post- nursing intervention, 1. Identify and address 1. Identifying and Goal met! The patient
kay alingasahandili ko operative recovery as the patient will the specific discomfort addressing the sleep quality improve
komportable” evidenced by frequent experience an improved or pain that is underlying cause of after administering
awakening due to sleep pattern for at least contributing to sleep discomfort is medication to relieve the
Objective: discomfort 4 hours with fewer deprivation. essential for discomfort and
- Presence of eye awakenings due to targeting the issue maintaining a quiet and
bags. discomfort 2. Provide additional at its source. comfortable room to
- Weakness and comfort measures, promote uninterrupted and
restlessness such as adjusting the 2. Offering additional support to the early stages
- Irritability patient's position in comfort measures, of post-operative
bed, using pillows, or such as adjusting recovery.
applying heat or cold the patient's
Vital signs as follows: packs to alleviate pain position and using
Bp: 130/80 mmHg or discomfort. heat or cold packs,
Temp: 36.5 c directly alleviates
RR: 28 CPM pain or discomfort,
HR- 86 bpm 3. Create a sleep- making sleep more
PR- 95 bpm conducive restful.
environment by
maintaining a quiet,
dark, and comfortable 3. Maintaining a
room. quiet, dark, and
comfortable room
4. Teach relaxation helps minimize
techniques, such as disturbances and
guided imagery, or creates an
progressive muscle environment that
relaxation, to help the supports better
patient manage stress sleep quality.
and promote better 4. These techniques
sleep. promote a more
relaxed state
5. .Encourage the patient conducive to sleep.
to establish a calming 0
bedtime routine, which 5. Activities like
may include activities reading or listening
such as reading or to soothing music
listening to soothing promote relaxation
music before sleep. before sleep.

6. Encourage the patient

to engage in gentle 6. . Gentle daytime
daytime activities and activities and
mobility to prevent mobility prevent
muscle stiffness and muscle stiffness
support a more restful and promote better
sleep. sleep by helping
the patient feel
more comfortable
7. Continuously monitor when lying down
the patient's sleep patterns to rest.
and mood. Document any
changes or improvements. 7. .Regular
monitoring of sleep
8. Administer prescribed patterns and mood
pain medications or other allows for the
comfort measures to assessment of the
relieve discomfort and effectiveness of
promote restful sleep. interventions.
Paracetamol 500mg for 1
dose via low as IV push 8. Administering
then after 6 hours prescribed pain
medications or
9. Educate the patient other comfort
on good sleep hygiene measures is
 practices, including necessary to
maintaining a provide pain relief
consistent sleep and promote restful
schedule, avoiding sleep.
caffeine and heavy
meals before bedtime, 9. Educating the
and limiting screen patient on good
time in the evening. sleep hygiene
practices promotes
10. Collaborate with the healthier sleep
healthcare team, including habits.
pain management
specialists or
psychologists, to ensure a
comprehensive approach 10. These
to addressing discomfort specialists can
and sleep deprivation. provide additional
expertise and
interventions to
support the
patient.