XI. NURSING CARE PLAN Post-operative NCP ASSESSMENT Subjective: Sobrang sakit, as verbalized by the patient.

Objective: -Pain scale= 8/10 -Teary eyed -(+) guarding behavior -(+) facial grimace -Irritable -Pale palpebral conjunctiva -Skin warm to touch follows: BP= 110/80 PR= 80 RR= 22 T= 37.6 DIAGNOSIS Acute pain r/t disruption of skin and tissue secondary to cesarean section. PLANNING INTERVENTION STG: Independent: After 1-2hr of nursing - Established rapport. intervention, patient will verbalize - Monitored vital decrease intensity signs. of pain from 8/10 to 3/10. - Assessed quality, characteristics, severity of pain. RATIONALE OUTCOME Goal met. After 2hrs of nursing intervention, the patient verbalized pain decreased from a scale of 8/10 3/20 as evidenced by (-) facial grimace (-) guarding behavior. Frequent small talks with significant others

-To have a good nurse-client relationship -To establish a baseline data -To establish baseline data for comparison in making evaluation and to assess for possible internal bleeding. -Calm environment helps to decrease the anxiety of the patient and promote likelihood of decreasing pain. - To check for diastasis recti and protect the area of the incision to improve comfort. And to initiate nonstressful muscle-

Provided comfortable environment changed bed linens and turned on the fan.

Instructed to put pillow on the abdomen when coughing or moving.

setting techniques and progress as tolerated, based on the degree of separation. Instructed patient to do deep breathing and coughing exercise. - For pulmonary ventilation, especially when exercising, and to relieve stress and promote relaxation. - To promote circulation, prevent venous stasis, prevent pressure on the operative site.

Provided diversionary activities. Initiate ankle pumping, active lower extremity ROM, and walking Collaborative: Administer analgesic as per doctors order.

-Relieves pain felt by the patient

ASSESSMENT Subjective: - none Objective: - dressing dry and intact follows: T: 37.3 P: 80 R: 19 BP: 120/80

DIAGNOSIS Risk for infection related inadequate primary defenses secondary to surgical incision

NURSING ANALYSIS Due to an elective cesarean section, patients skin and tissue were mechanically interrupted. Thus, the wound is at risk of developing infection.

PLANNING STG: After 4 hours of nursing intervention, patient will be able to understand causative factors, identify signs of infection and report them to health care provider accordingly. LTG: After 2-3 days of nursing intervention, patient will achieve timely wound healing, be free of purulent drainage or erythema, be afebrile and be free of infection.

INTERVENTION Independent -Monitor vital signs -Inspect dressing and perform wound care - Monitor white blood count (WB

RATIONALE

EVALUATION

-To establish a baseline data -Moist from drainage can be a source of infection - Rising WBC indicates bodys efforts to combat pathogens; normal values: 4000 to 11,000 mm3 -these are signs of infection

Patient is expected to be free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.

- Monitor Elevated temperature, Redness, swelling, increased pain, or purulent drainage at incisions - Wash hands and teach other caregivers to wash hands

-Friction and running water effectively remove microorganisms

before contact with patient and between procedures with patient.

from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another - Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI). - These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia. -Antibiotics have bactericidal effect that combats

- Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated).

- Encourage coughing and deep breathing; consider use of incentive spirometer.

Independent: - Administer antibiotics

pathogens

ASSESSMENT Objective Cues: Patient has not yet eliminated since delivery Absence of bruit sounds Normal pattern of bowel has not yet returned

NURSING DIAGNOSIS Risk for constipation r/t post pregnancy 2 cesarean section

PLANNING Short Term Goal: Within 8 of nursing interventions, the patient will be able to demonstrate behaviors or lifestyle changes to prevent developing problem

INTERVENTIONS INDEPENDENT INTERVENTIONS: Ascertain normal bowel functioning of the patient, about how many times a day does she defecate Encourage intake of foods rich in fiber such as fruits

RATIONALE

EVALUATION

Long Term Goal: Within 3 days of

Promote adequate fluid intake. Suggest drinking of warm fluids, especially in the morning to stimulate peristalsis Encourage ambulation such as

After 8 of nursing interventions, This is to determine the the patient was normal bowel able to identify pattern measures to prevent infection To increase the as manifested by bulk of the clients stool and verbalization of: facilitate the Iinom ako ng passage through the maraming tubig colon at kakain ng To promote prutas para moist soft stool makadumi ako.

To stimulate contractions of the intestines

nursing interventions, the patient will be able to maintain usual pattern of bowel functioning

walking within individual limits However, since she has had cesarean, also encourage adequate rest periods

and prevent post operative complications To avoid stress on the cesarean incision/ wound

COLLABORATIVE: Administer bulkforming agents or stool softeners such as laxatives as indicated or prescribed by the physician To promote defecation