Nursing Backgrou INFEREN Goals and Interventions Rationale Evaluation

Diagnosis nd Study CE Objectives

Impaired Skin is the GOAL:
Skin/Tissue body’s first Emergenc After 3 days of Goal met as
Integrity line of y CS nursing evidenced
related to defense interventions, the by the
mechanical against patient will be able patient has
trauma of foreign to display timely able to
surgical materials Abdomina healing of skin display
removal of that can be l incision lesions/ wounds timely
skin and considered and without healing of
subcutaneou as injuring Uterine complication. Independent skin lesions/
s tissue agents. incision wounds
secondary to Once the OBJECTIVES: Establish rapport To gain trust without
with the client
Cesarean skin is After 8 hours of complication
section disrupted, nursing .
this will put Alteration interventions, the Perform bedside
care To enhance
Assessment a person at s of the patient will be able
patient’s self
Subjective: risk since it Skin to:
esteem and to
“Mayda ak may • Participate provide
samad kay become a in comfort to the
gin Cesarean good prevention patient
ak paganak,” medium for measures
verbalized by bacterial and Inspect skin on
the client. growth. treatment daily basis and
Objective: Cesarean program obseve for To determine
Destruction section, changes and unusual ties
• Maintain
of skin layers like any unusualities and report it
physical
Desruption of other well-being. to physician
tissue layers. surgical • Ability to for prompt
(+)Redness procedures manage treatment.
on the , includes Keep the area
situation.
incision site. invasion of clean, carefully This will assist
(+)Swelling the inside dress wound,
on the body, support incison, body’s natural
incision site specifically prevent infection process of
the skin repair
and Encourage client
subcutaneo to demonstrate
us area. good skin
hygiene, e.g., Maintaining
(NANDA 9th wash thoroughly clean, dry skin
edition.pp and pat dry provides a
461-465) carefully after barrier to
teaching.
infection.
(Med-
Surgical Patting skin
Nursing, dry instead of
Black and rubbing
Hawks 8th reduces risk of
Edition pp DEPENDENT dermal
952-954) Medication such trauma to
as antibiotics
fragile skin

To prevent
COLLABORATIV post operative
E wound
Provide optimum complication
nutrition such as
increased protein
intake. To provide a
positive
nitrogen
balance to aid
in healing.

(NANDA 9th
edition pp
461-465)
(Med-Surgical
Nursing, Black
and Hawks 8th
 Edition pp
952-954)

Nursing Backgroun INFERENC Goals and Interventions Rationale Evaluatio

Diagnosi d Study E Objectives n
s
Acute Pain is Emergency GOAL:
pain defined as CS At the end of my Goal met
related to unpleasant nursing as
intervention of 8 evidenced
abdomina sensory
Abdominal by the
l incision and hours duty, the
and uterine patient
secondary emotional incision patient will be able has able
to experience to report pain is to
surgery. arising relieved or manage
from actual Tissue controlled. Independent pain
Subjecti or potential trauma To easily gain relieve
OBJECTIVES: Establish cooperation form and
ve cues: tissue
By the of 1hour of rapport to the the patient controlled
“Masakit damage or patient
my nursing from 4to 6
pa an described Prostagland intervention, the To have baseline to 2-3 on
tinahian in terms of in release+ client will: data and for the pain
han han such Uterine Monitor Vital comparison for rating
ak tiyan damage. Contraction • Report pain signs future data scale.
nan (Internation + Loss of intensity
nakukuria Anesthetic from 4 to 6 To enhance
al
n ak Effect Perform patient’s self
Association will
bedside care esteem and to
pagkiwa” for the decrease at provide comfort to
as
verbalized Study of 2 to 3 from the patient
by the Pain); Sensation 0 to 10 pain
patient. of Pain scale. Observe and By getting the
document following
Objectiv • Participate location, information, we are
e cues: (Nurse’s severity and asssitting in
in
Pocket Elevated character of differentiating
Vital Signs demonstrati pain. cause of pain and
Temp: Guide)
ng providing
38.4
techniques information about
°C
to relieve disease
PR: 88
pain progression/resoluti
bpm
on, development of
RR: 24 complications and
cpm • Have ability
to manage effective
BP: Promote interventions.
130/90 situation.
bedrest,
mm allowing patient Bedrest in low-
Hg to assume fowler’s posiiton
Rated position of reduces
pain comfort intraabdominal
as 4 to pressure.
6 out Control
of 0 to environment
10 temperature Cool surrounding
pain aids in minimizing
scale. Employ non dermal discomfort.
Pain pharmacologic
increa pain distraction
ses such as: To prevent
when Music therapy, dependecy on
moves Imagery,etc medication for pain
vigoro
usly DEPENDENT
Incision Medication
site: such as
Wound: NSAID’s Relieves pain
dry, no immediately.
discharge
s noted
(NANDA 9th edition
Dressing pp 461-465)
and
plaster
were
clean and
fully
covered
the
incision
site

No foul
odor
noted on
the site.