Nursing Dx: Deficient Knowledge R/t Lack of information
Assessment Planning
Objective Cues: At the end of my 8 hour duty
there will be enhancement on
Did not correctly wear abdominal clients knowledge regarding
binder. Recent condition as evidenced
by:
Does not Breastfeed Child.
Ability to wear and put on binder
Subjective Cues: on the correct place, that is just
on the level of the surgical
Does not Move in and out of bed incision.
due to fear of wound laceration
and dehiscence.
Know the advantages of breast
Constantly wearing Diaper feeding.
Ability to ambulate and move in
and out of bed.
Ability to not rely on diaper for
elimination.
Intervention Rationale
1. Established Rapport.
2. Health teaching made
about proper use of
binder the position and
tightness.
3. Heath teaching made
about the importance of
breast feeding.
4. Encouraged to ambulate
5. Health teaching about
the importance of early
ambulation.
6. Give accurate
information in easy-to-
understand terms and
clarify misconceptions.
7. Educate patient
postoperatively;
including demonstration
of leg exercises, proper
Evaluation
1. To secure client At the end of my 8 hour duty the
cooperation goals of enhancing client
knowledge about current status
2. To properly put support is partially met as evidenced by:
on the incision site
preventing wound ability to wear and place
dehiscence when abdominal binder in the correct
moving. place for support on surgical
wound
3. To help convince the
mother to rely on breast Verbalized understanding of the
milk rather than formula importance of breastfeeding but
milk. still does not breastfeed child
4. To promote proper body Does Move in and out of bed
circulation and slowly.
peristalsis.
Goes to the bathroom when urge
5. For client education. to urinate and defecate is felt.
6. Stress of the situation
can affect the patient’s
ability to understand
information required to
make informed
decisions.
7. Provides routine to
prevent complications
associated with venous
stasis and
coughing and deep hypostatic pneumonia,
breathing techniques, and to lessen stress on
splinting, and abdominal the operative site.
tightening exercises. Abdominal tightening
reduces distress
associated with gas
formation and
abdominal distension.
Nursing Dx: Activity Intolerance R/t Pain
Assessment
Objective Cues:
Facial grimacing when moving
pain scale of 7/10 when moving. as evidenced by:
Guarding behavior in the surgical
site in the abdomen when
moving.
Vital signs 5 minutes after sitting
in the chair
Temperature:36.6
Pulse Rate:116
Respiratory Rate:28
BP:100/60
Subjective Cues:
Client verbalized “ Sakit jud kaau
I lihok mag lisod ko og tikang,
lingcod og tindog kay inig ma piit
akong tiyan sakit jud siya.
“malipong ko og mo tindog”
Planning
At the End of my 8 hour duty
there will be ability to manage
and control activity intolerance
due to pain using other measures
Ability to perform deep
breathing exercised when pain is
felt when moving.
Willingness to take pain
medications as prescribed.
Ability to use diversional
activities such as talking,
listening to music when pain is
felt.
Ability to control pain by slowly
and gradually moving and not
forcing self in doing task quickly
when ambulating.
Pain scale will be decreased at
least 6/10
Intervention
Establish rapport to client.
Health teaching about other
measures to combat pain such as
imagery, music therapy.
Encourage client to ambulate
slowly, standing slowly and
dangling legs before moving out
of bed.
Monitor location, intensity, type
of pain and what aggravates it.
Drop anxiety-producing
circumstance (e.g., loss of
control), give accurate
information, and encourage
presence of partner.
COLLABORATIVE:
If indicated, administer
medications such as
sedative, narcotics, or
preoperative drugs.
Rationale Evaluation
To gain Client cooperation. At the end of my 8 hour duty the
goal of achieving ability to
May help in decreasing anxiety control and manage activity
and tension, promote comfort intolerance due to pain is fully
and enhance sense of well-being. met as evidenced by:
Prevent orthostatic hypertension Ability to perform deep
and unnecessary discomforts breathing exercises properly.
when standing.
Willing to take pain medications
as ordered.
Indicates the suitable choice of
treatment. The patient Proper utilization of diversional
awaiting imminent cesarean activities during times when pain
birth may encounter varying is felt during and after
degrees of discomfort, ambulation.
depending on the indication for
the procedure. Moves slowly in and out of bed.
Levels of pain tolerance are
individual and are affected by Pain scale of 6/10 as reported.
various factors. Extreme anxiety
following an emergency situation
may develop discomfort due to
fear, tension, and pain affecting
the patient’s ability to cope.
Promotes comfort by blocking
pain impulses. Potentiates the
action of anesthetic agents.
Nursing Dx: Risk for deficient fluid volume R/t Blood loss during surgical operation.
Assessment Planning Implementation Rationale Evaluation
Objective Cues: At the end of my 8 hour duty Establish rapport To gain client cooperation. At the End of my 8 hour duty the
there will be willingness to goal of achieving willingness and
Pail nail beds, sclera, lips and enhance fluid volume and prevent complications of
buccal mucosa. prevent complications as Remove nail polish on Essential for clear visualization of deficient fluid volume is fully met
evidenced by: fingernails/toes. nailbeds for assessing circulatory as evidenced by:
Capillary refill :3 Seconds status
Willingness to consume at least Consumption of 7 glasses of
Dry Skin 8-10 glasses per day as ordered Check respirations, BP, and pulse Hypotension is an expected side water per day.
before, during, and after effect of regional anesthesia
urinates only 2-3 times per day Prevent sudden falls and injury administration of anesthesia. (e.g., epidural or spinal Did not have any signs of injury
approximately 30ml only per during ambulation. anesthesia) because such from any cause.
urination. anesthesia relaxes smooth
Utilize moisturizing lotion to muscles within vascular walls, Ability to consider using
Reports of dizziness when prevent skin irritation. affecting circulating volume and moisturizing lotions, lip products
standing. reducing placental perfusion. that is to prevent skin irritations.
Take rest and sleep during noon
Vital signs: and 6-8 hours at night Place towel or wedge under Shifts uterus off inferior vena Ability to take noon naps and
Temperature: 36.6 ‘C patient’s hip. cava and increases venous sleeps 6-7 hours every night.
Pulse Rate: 98 return. Compression caused by
Respiratory Rate:21 obstruction of the inferior vena
Blood pressure:90/60 cava and aorta by the gravid
uterus in a supine position may
Drinks only 3-6 glassess of water cause as much as a 50%decrease
per day. in cardiac output.

Note shift in behavior or mental Oxygen deficits are manifested

status, cyanosis of mucous first by changes in mental status,
membranes. later by cyanosis.
COLLABORATIVE:
Initiate IV infusion of electrolyte
solution. Administer bolus, as
indicated.
Note alteration in vital signs;
assist anesthetist as needed.
Estimate and record blood
losses.
Expands circulatory volume,
especially prior to administration
of epidural or spinal anesthesia;
provides route for emergency
medication in the event of a
complication.
Excess fluid losses and
hemorrhage during labor and the
intraoperative period may reduce
cardiac output and promote
vasoconstriction with shunting of
blood to major organs.
Diminished cardiac output and
shock are manifested by
decreased BP, increased or
thready pulse, and cool or
clammy skin.
 Andres Bonifacio College
School of Nursing
College park, Dipolog City

Nursing Care Plan

Submitted by: Mr. Roeder Cuerda BSN-IV
Submitted to: Mrs. Josephine E. Yurong RN,MN