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 -V/S taken as 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 STG: After 1-2hr of nursing intervention, patient will verbalize decrease intensity of pain from 8/10 to 3/10.
INTERVENTION Independent:
RATIONALE
Established rapport.
-To have a good nurse-client relationship
Monitored vital signs.
-To establish a baseline data
Assessed quality, characteristics, severity of pain.
-To establish baseline data for comparison in making evaluation and to assess for possible internal bleeding.
Provided comfortable environment – changed bed linens and turned on the fan.
-Calm environment helps to decrease the anxiety of the patient and promote likelihood of decreasing pain.
Instructed to put pillow on the abdomen when coughing or moving.
- To check for diastasis recti and protect the area of the incision to improve comfort. And to initiate nonstressful muscle-
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
setting techniques and progress as tolerated, based on the degree of separation.
Instructed patient to do deep breathing and coughing exercise.
Provided diversionary activities. Initiate ankle pumping, active lower extremity ROM, and walking Collaborative: Administer analgesic as per doctor’s order.
- 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.
-Relieves pain felt by the patient
ASSESSMENT Subjective: - none Objective: - dressing dry and intact -V/S taken as 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, patient’s skin and tissue were mechanically interrupted. Thus, the wound is at risk of developing infection.
PLANNING
INTERVENTION
RATIONALE
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.
Independent -Monitor vital signs
-To establish a baseline data
-Inspect dressing and perform wound care
-Moist from drainage can be a source of infection
- Monitor white blood count (WB
- Rising WBC indicates body’s efforts to combat pathogens; normal values: 4000 to 11,000 mm3
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
- Monitor Elevated temperature, Redness, swelling, increased pain, or purulent drainage at incisions
-these are signs of infection
- Wash hands and teach other
-Friction and running water
EVALUATION Patient is expected to be free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.
free of infection.
caregivers to wash hands before contact with patient and between procedures with patient.
effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another
- Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated).
- 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).
- Encourage coughing and deep breathing; consider use of incentive spirometer.
- These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia.
Independent:
-Antibiotics have
-Administer antibiotics
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 8º 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
•
Long Term Goal: Within 3 days of
bactericidal effect that combats pathogens
•
Promote adequate fluid intake. Suggest drinking of warm fluids, especially in the morning to stimulate peristalsis Encourage ambulation such as
RATIONALE
•
•
•
•
EVALUATION
After 8º of nursing interventions, the This is to determine the patient was able normal bowel to identify pattern measures to prevent infection To increase the as manifested by bulk of the client’s 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
