PHINMA University of Pangasinan
College of Health Sciences
NURSING CARE PLAN
Patient’s Initials: Chief Complaint: Name of the Student
Nurse:
Age & Gender: Admitting Diagnosis:
Level/Block/Group:
Birthdate:
Date of Confinement: Clinical Instructor/s:
Address:
Date:
NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
ANALYSIS
Analysis A:
The patient is
Subjective Data: susceptible to
• “My incision hurts when disruption of the
I move.” interactive process
• “I feel weak and anxious between parent and
about my wound infant that fosters
healing.” protective and nurturing
Objective Data: behaviors through
reciprocal bonding.
• Pain 7/10 at incision site.
Post-operative pain,
• Facial grimacing during
surgical recovery, and
repositioning.
maternal anxiety may
• Limited ambulation; interfere with the early
needs assistance. attachment process
• Vital Signs:
BP 118/78 mmHg, Analysis B
HR 90 bpm, Pain is defined as an
RR 22, unpleasant sensory and
Temp 37.5°C. emotional experience
associated with actual
or potential tissue
damage. In this case,
pain is acute in nature,
with sudden onset
following surgical
intervention. It may
present with mild to
severe intensity and
typically lasts less than
three months.
Analysis C
The patient
demonstrates an
absence of essential
information related to
the surgical procedure
and post-operative
care. This indicates
limited awareness or
access to resources,
uncertainty in self-care,
and a need for further
teaching to enhance
understanding and
participation in care
planning.
NURSING DIAGNOSIS
Risk for impaired attachment
possible evidence by
developmental transition or gain
of family member situation
crisis(e.g.., surgical intervention,
physical complication interfering
with initial acquaintance, and
interaction negative self
appraisal)
Acute pain/Impaired comfort
may be related to surgical
trauma effect of anesthesia,
hormonal effects, bladder or
abdominal distension possible
evidence by verbal report (e.g..,
incisional pain, cramping, after
pain, spinal headache), guarding
or destruction behavior
irritability facial mas of pain
Deficient knowledge regarding
surgical procedure and
expectation postoperative
routines and therapy and self
care needs may be related to
lack of information/
misinterpretation possible
evidence by statement of
concern, question and
misconception.
Scenario: Post-Operative Cesarean Section
Ana Dela Cruz, a 30-year-old primigravida, was admitted to the obstetric ward on September 15, 2025, following a
scheduled Cesarean Section at 39 weeks gestation due to cephalopelvic disproportion (CPD). On the first post-
operative day, she complained of incisional pain, particularly when moving or attempting to get out of bed.
She reported feeling weak and anxious about wound healing and caring for her newborn. Vital signs were stable
(BP 118/78 mmHg, HR 90 bpm, RR 22, Temp 37.5°C). Her abdominal incision had a dry, intact sterile dressing, but
she demonstrated limited ambulation due to pain, with facial grimacing when repositioning.
The nurse observed that Ana required assistance in mobility and self-care and needed continuous guidance on
wound care and infection prevention.