The nursing care plan addresses two nursing diagnoses: deficient fluid volume related to blood loss and activity intolerance related to cesarean section. Short term and long term goals are outlined to monitor bleeding, vital signs, pain levels, and increase mobility. Dependent, independent, and collaborative interventions include medication administration, education, exercise, and physical therapy referral to manage symptoms and improve the patient's condition over time.

1. COMPREHENSIVE NURSING CARE PLAN
Nursing Diagnosis: Deficientfluidvolume relatedtobloodloss
Date of Assessment: Date of Evaluation:
Assessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Interventions
Rationale Evaluation
Subjective
Data:
1. “Nurse
masyado po
atang madami
discharge ko”
as verbalized
by the mother
2. Normal
lang po ba
dami nang
lumalabas?
Sources:
Nurseslabs, P.
Martin 2019
NANDA
International
“Nursing
Diagnoses
Definitions and
Classification,
Herdman H.,
Kamitsuru
S., 2018-2020,
11th edition,
page 425
Short Term:
1. For the
first hour,
evaluate
discharge
every 15
minutes,
noting:
a.color
b.amount
c.odor
d.clots
2. Examine
your vitals
3. Examine
the uterus's
condition or
form.
Dependent:
1. oxygen should be
administered
2. As prescribed by
doctor, administer
drugs such as
oxytocin.
3. blood transfusion.
Dependent:
1. to supply enough
oxygen needed by the
mother
2. To halt bleeding or
blood loss, to induce
contractions, and to
avoid complications
3. Due to blood loss,
blood transfusions are
given if there is too
much blood loss
Short Term:
1. Goal met
Discharge is
dark red in
color
2. Goal met
From large
clots to small
clots
3. Goal met
Stable vital signs.

2. Objective
Data:
1. Irritability
2. Rigid
Uterus
3. Incision on
the abdomen
(low segment
incision)
4. Vital
Signs:
Temperature:
36.7 ℃
Pulse: 85
bmp
Respiration:
BP: 140/90
Oxygenation:
90
Blood loss:
1,200 ml
Long Term:
1. vital signs
will be stable
after 8 hours
of monitoring
2. Correct
pattern of
lochia
Independent:
1. Asses excessive
bleeding and
immediately call the
doctor
2. weighing all of the
mother's perineal
pads to assess the
amount of blood
3. Providing
instruction to the pt.
If she passes clots,
she should notify the
nurse noting of their
size and amount.
4. oxygen should be
administered
5. Uterine massaging
6. Care for the
Perineum
7. lochia color,
quantity, and pattern
health education
8. encourage mother
for breastfeeding
Independent:
1. Excessive bleeding
should be reported to
the doctor for further
investigation.
2. To find out how
much blood has been
lost.
3. Uterine
contractions are
indicated by a
considerable number
of clots.
4. 1-2 liters of oxygen
are administered by
nurses via nasal
cannula.
5. Contractions and
bleeding can be
avoided by
massagingthe uterine
fundus.
6.Changing per pads
and using a Sitz bath,
as well as wiping from
front to back, limit the
spread of
microorganism
existing in the anus.
7. Pt. will benefit from
health education
Long Term:
1. Goal met,
after 6 hours,
the lochia flow is
within normal
range until
discharge.
2. Goal met, no
unpleasant odor
was detected
3. Goal met
Patients show
understanding
of the optimal
lochia color,
amount, and
pattern, which
will be reported
if possible.

3. 9. monitor the rate of
involution and check
the color including
amount of discharge
10. check REEDA
on the abdominal
incision site
11. assess vital signs
every15 minutesfor
the firsthour after
surgery,every30
minutesforthe next2
hours,everyhourfor
the next4 hours,or as
specificallyordered(
Collaborative:
1. Removal of left
parts of clots
2. Examine WBC
count, hemoglobin
and hematocrit levels
regarding discharges
to reported by any
unfavorable findings
8.
9.
Collaborative:
1.To stop the
excessive bleeding
2. Infection is
indicated by a rise in
WBC.

4. Nursing Diagnosis: Activity intolerance related to CS secondary to surgical incision as evidenced by lying on bed all the
time
Date of Assessment: February 15, 2022 Date of Evaluation: February 17, 2022
Assessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Interventions
Rationale Evaluation
Subjective
Data:
1.“ wala po ako
gana mag galaw-
galaw, gusto ko
naka higa lang”
as verbalized by
the mother
2. “masakit pa
kase tong
operasyon ko
nurse” as the
mother added
3. mother
verbalized that
she is having
discomfort and
difficulty
performing
ADL’s
4. 7/10 pain scale
Activity
intolerance
related to CS
secondary to
surgical
incision as
evidenced by
lying on bed
all the time
Insufficient
physiological
or
psychological
energy to
endure or
complete
required or
desired daily
activities.
Source:
- NANDA
International
“Nursing
Diagnoses
Definitions and
Classification,
Herdman H.,
Kamitsuru
S., 2018-2020,
11th edition,
page 246
Short Term:
1.For 10
minutes,
conduct
interview to
the mother
about her
feelings and
pain sensations
2. For 10 hours
monitor vital
signs
3. After 12
hours of
nursing
interventions
the mother will
be able to
verbalized the
activities that
she cannot
perform and
factors that
contributes to
immobility
4. After 24
hours, mother
Dependent:
1. Administer
non- opiod
analgesic
500 mg as
ordered
through IV
2. Order stool
softener
Dependent:
1.Promotes
comfort by
blocking
sensations. IV
infusion is used
for post-partum
CS mothers since
they are NPO for
6-8 hours
2.Stool softeners
are used to avoid
constipations in
order for the
mother to tolerate
bathroom
activities
Short Term:
1.Goal
partially met,
interview was
done but
mother was a
not totally
verbally
responsive.
2. Goal met,
vital signs
were assessed
within normal
unit with a
Vital Sign:
Temperature-
36.5 degrees
Celsius
BP- 125/80
mmHg
Pulse- 90 bpm
RR- 24 bpm
3. Goal met,
mother was
able to
verbalized

5. will be able to
perform
limited
activities with
assistance
factors that
contributes
activity
intolerance
4. Goal
partially met,
after 24 hours’
postpartum
mother was
able to
perform
several ADL’S
with complete
assistance and
wants to just
lei and rest in
bed.
Objective Data:
1. Incision on the
abdomen (low
segment
incision)
2. Patient is
always lying on
bed
3. Needs
assistance when
performing
activities of daily
living
Long Term:
1.After 4 days
of
hospitalization
and nursing
intervention,
patient will be
able to perform
tolerance in
doing ADL’s
as evidenced
by being able
to sit and comb
her hair and
Independent:
1. Assessmother’s
vital indicators,such
as:
a. temperature
b.heartrate
c.bloodpressure
d. usage of accessory
muscles
e.skincolor
2.Encourage mother
to complete activity
at a slowerpace,
overa longerperiod
Independent:
1. A motherwhois
showingsignsof
shockor
postpartum
hemorrhage should
be referred
immediately.If
motherisgoinginto
shock,herblood
pressure istoolow
and falling,andher
pulse rate istoo
highand rising.If
Long Term:
1. Goal
partially met,
after 4 days of
hospitalization
and nursing
intervention,
patient was
able to
perform
tolerance in
doing several
ADL’s as
evidenced by

6. Vital Sign:
Temperature-
37.5 degrees
Celsius
BP- 125/80
mmHg
Pulse- 90 bpm
RR- 24 bpm
walk during
rooming in
of time,withmore
restand
interruptions,orwith
assistance
3. Promote bedrest
and assistpatientto
lie supine for8 hours
afterspinal
anesthetic
4. For 10 to 15
minutes,assist
patienttodangle legs
fromthe bedside
5. As preferredbythe
patient,provide a
commode at the
bedside
6. Promote an
increase activity
graduallybydoing
active range-of-
motionexercisesin
bed,thensittingand
finallystanding
7. Assistmotherin
herADLs while
remaining
independentof the
patient.
8. Promote non-
pharmacologic
measureslike
there are no signsof
bleedingfromthe
vaginal area,she
may be losingblood
inside
2.It promotes
developmentof
tolerance forthe
activity
3. To regain
strength and
energy
4.It prevents
orthostatic
hypotensionfrom
occurring
5. Using a commode
consumesless
energythanusinga
bedpanor walking
to the bathroom
6. Overexertionis
avoidedby
graduallyincreasing
the activitylevel or
intensity.Passive
range of motionis
importantfor
maintainingmuscle
and jointflexibility
by allowingmuscles
to move passively
7. Assistingthe
patientwithADLs
being able to
sit and comb
her hair but
when walking
and in doing
some activities
like walking
during
rooming in and
carrying her
baby she still
needs
assistance.

7. changinginposition
and arrangingbed
linenscanhelp
promote comfort
9. Instruct and
encourage the
womanto walk
duringroomingin
10.Patientmustbe
tiltedleftandright
every6-10 hours.
Checktensioninthe
calf and humansign
11. Promote early
mobilizationmaydo
ismove the arm,
hand,move the toe
and ankle twisting,
elevatingthe heel,
calf musclestight,as
well asbendingand
slidingthe footinthe
first6 hours
postpartum
12. Instructthe
postpartummother
on energy-saving
techniques,suchas
sittingtobrush teeth
or comb hair,and
performingtasksata
slowerspeed.
conservesenergy;
carefullybalance
assistance;
facilitatinggrowing
endurance will
improve the
patient’sactivity
tolerance andself-
esteem
8. In orderfor the
motherto notrely
to painmedications
9. It is the bestway
to ease gas pain
10. To avoid
thrombosisand
embolismfrom
occurringor Deep
veinthrombosis
(DVT)
11. Early ambulation
makesmotherfeel
healthierand
stronger.By
mobilizingregular
bloodcirculation/
smooth,the danger
of thrombosisand
thromboembolism
can be reduced.
Usedto strengthen
musclesand joints
inorder to conduct
activities

8. 13. Astolerated,
elevate the headof
the bed
14. Assesspain scale
15. Teach motheras
she feedsthe baby to
put a pillowonher
lap.
16. Football holdfor
breastfeeding
12. Energy-saving
strategieshelpto
equalize oxygen
supplyanddemand
by loweringenergy
consumption
13. Improveslung
expansionforbetter
oxygenationand
cellularabsorption
14. Enable patient
to rate the severity
of herpain
15. to alleviatepain
by shiftingthe
infant’sweight
away fromthe
suture line
16. a technique for
keepingthe baby’s
weightoff the
mother’sincision
Collaborative:
1.As needed,seek
physical/occupational
treatment.
2.Involve and
encourage S.Oin
assistingthe needfor
additional assistance
at home
Collaborative:
1.May be
required/desiredin
orderto design
individualized
exercise/progressive
activityprograms
2.In aidingthe
patientin
conservingenergy,
coordinatedefforts
ismore effective

9. COMPREHENSIVE NURSING CARE PLAN
Nursing Diagnosis:
Date of Assessment: Date of Evaluation:
Assessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Interventions
Rationale Evaluation
Subjective Data: Short Term:
1.
Dependent:
1.
Dependent:
1.
Short Term:
1.
Objective Data:
1
Long Term:
1
Independent:
1.
Independent:
1.
Long Term:
Collaborative:
1.
Collaborative:
COMPREHENSIVE NURSING CARE PLAN
Nursing Diagnosis:
Date of Assessment: Date of Evaluation:
Assessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Interventions
Rationale Evaluation
Subjective Data: Short Term: Dependent: Dependent: Short Term:

10. 1. 1. 1. 1.
Objective Data:
1
Long Term:
1
Independent:
1.
Independent:
1.
Long Term:
Collaborative:
1.
Collaborative:
COMPREHENSIVE NURSING CARE PLAN
Nursing Diagnosis:
Date of Assessment: Date of Evaluation:
Assessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Interventions
Rationale Evaluation
Subjective Data: Short Term:
1.
Dependent:
1.
Dependent:
1.
Short Term:
1.
Objective Data:
1
Long Term:
1
Independent:
1.
Independent:
1.
Long Term:
Collaborative: Collaborative:

11. 1.
COMPREHENSIVE NURSING CARE PLAN
Nursing Diagnosis:
Date of Assessment: Date of Evaluation:
Assessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Interventions
Rationale Evaluation
Subjective Data: Short Term:
1.
Dependent:
1.
Dependent:
1.
Short Term:
1.
Objective Data:
1
Long Term:
1
Independent:
1.
Independent:
1.
Long Term:
Collaborative:
1.
Collaborative:
COMPREHENSIVE NURSING CARE PLAN
Nursing Diagnosis:
Date of Assessment: Date of Evaluation:
Assessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Interventions
Rationale Evaluation
Subjective Data: Short Term: Dependent: Dependent: Short Term:

12. 1. 1. 1. 1.
Objective Data:
1
Long Term:
1
Independent:
1.
Independent:
1.
Long Term:
Collaborative:
1.
Collaborative:
COMPREHENSIVE NURSING CARE PLAN
Nursing Diagnosis:
Date of Assessment: Date of Evaluation:
Assessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Interventions
Rationale Evaluation
Subjective Data: Short Term:
1.
Dependent:
1.
Dependent:
1.
Short Term:
1.
Objective Data:
1
Long Term:
1
Independent:
1.
Independent:
1.
Long Term:
Collaborative: Collaborative:

13. 1.
COMPREHENSIVE NURSING CARE PLAN
Nursing Diagnosis:
Date of Assessment: Date of Evaluation:
Assessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Interventions
Rationale Evaluation
Subjective Data: Short Term:
1.
Dependent:
1.
Dependent:
1.
Short Term:
1.
Objective Data:
1
Long Term:
1
Independent:
1.
Independent:
1.
Long Term:
Collaborative:
1.
Collaborative: