Chapter VIII NURSING CARE PLAN

Assessment

Nursing Diagnosis Risk for infection related to inadequate primary defenses secondary to surgical incision

Planning

Intervention

Rationale

Evaluation

Subjective: none Objective: Dressing dry and intact BP- 180/120 PR- 83 RR- 22 TEMP- 36.3

After 4 hours of nursing care, the pt. will be able to understand causative factors, identify signs of infection and report them to health care provider accordingly.

Independent -Established rapport -Monitor vital signs

Pt. is expected to be free of infection, as -Inspect dressing evidenced by and perform absence of wound care as purulent ordered -rising WBC drainage from Indicates bodys wounds, -Check for white effort to combat incisions and blood count tubes -pathogens; normal values: -Monitor elevated 400 to 11,000 temp., redness, mm3 swelling , increase -these are signs pain, or purulent of infection drainage at incisions -friction and -Wash hands and running water teach other effectively remove caregivers to microorganisms

-promote cooperate on to the pt. -to established a baseline data -moist from drainage can be source of infection

Goal partially met

wash hands before contact with pt. and between procedures with pt.

fro hands.

Dependent -Administered antibiotics as ordered by the physician Such as cefuroxime

-antibiotics have bactericidical effect that combats pathogens

Assessment

Nursing Diagnosis Risk for skin integrity r/t alternation in skin turgor presence of edema

Planning

Intervention

Rationale

Evaluation

Subjectivenanghupong akoang tiil as verbalized by the patient

At the end of the shift the patient will maintain an intact skin

-Establish rapport - bedside care done -- monitor and recorded the v/s - instructed the patient to elevate her legs when sitting - encourage the patient to wear loose fitting garments

- to gain cooperation with the client -to obtain baseline of data -to enhance venous return and reduce edema formation -prevent skin irritation and promote evaporation of moisture in the skin -to enhance circulation

Goal not met the patient is still with edema

Objective: -presence of edema in lower extremities -redness in skin noted --swollen legs noted

-encourage to do some activities like walking -encouraged to put some ointment if prescribed or lotion.

-to relieve dryness

Assessment Subjective: Sakit akong tahi as verbalized by the client

Nursing Diagnosis Moderate pain r/t incision at midlower abdominal area secondary to cesarean section

Planning

Intervention

Rationale

Evaluation

Within 2 hours of intervention the patient will be able to: -Verbalized decrease of pain -Pain scale 7/10 will be decreased to 4/10

Independent: - monitor vital signs - assess for referred pain -for further monitoring -to help determine possibility of underlying condition or organ dysfunction requiring treatment. -pain is subjective experience and cannot be felt by others.

Goal not met with pain scale 7/10

Objective : -facial grimace -pain scale 7 out of 10 - body weakness noted - skin warm to touch - limited movement -guarding behavior to the incision site

-use pain rating scale. Acknowledge the pain experience and convey acceptance of clients response to pain. -encouraged to verbalize any pain.

-to maintain acceptable level of pain -to reduce tension

-encouraged to use relaxation technique such as deep breathing -to prevent fatigue -encouraged

adequate rest period Dependent -administer analgesics as indicated. -notify physician if regimen is Inadequate Assessment Nursing Diagnosis Ineffective tissue perfusion : cardiopulmonary; gastrointestinal and peripheral r/t hypertension and decreased cardiac output as manifested by blurred vision and increased blood pressure Planning Intervention Rationale Evaluation -to meet pain control goal.

Subjective: medyo nahihilo ako tsaka nanlalabo ang aking paningin as verbalized by the client. Objective: -increased blood pressure -B/P- 180/110 - body weakness noted - limited movement

At the end of the shift the clients blood pressure will be w/in set parameters for the client

Independent: -monitor v/s at least q 2 hrs especially the B/P -observe for complains of blurred vision -encouraged the patient to avoid any stressful problems -instructed the patient to have low salt and low -to monitor baseline data

Goal partially meet; the clients blood pressure decrease from 180/110 to 160/100

-to check the condition of the patient -it will help to decrease blood pressure -to prevent from increased BP

fat diet. -instructed the patient to have daily exercise as tolerated INDEPENEDENT: Due meds given by NOD ( methyldopa)

Assessment Subjective: sakit akong totoy pag nagapasuso ko sa akong baby, as verbalized by the patient. Objective: -swollen and nipple sores noted -red rashes around the nipple - facial grimacing

Nursing Diagnosis Ineffective breastfeeding related to nipple sores secondary to red rashes around the nipple

Planning

Intervention

Rationale

Evaluation Goa l partially met as evidenced by the mother knows what is proper breastfeeding but the nipple sores and swollen did not diminished.

After 8 hours of nursing intervention, the patient will be able to breastfeed her baby effectively and nipple sores and rashes will be diminished

Established rapport to the patient- Instruct the mother the proper breastfeeding. - Recommend using a variety of nursing positions, - Provide health teachings: a. Wear 100% cotton fabrics. b. Don't use soap, alcohol or drying agents on

To provide trust.

-it helps to provide support with the mother as well as the baby.

nipples. c. Avoid use of nipple shields or nursing pads that contains plastics. d. Administer mild pain reliever as ordered. e. Apply ice before nursing. f. Soak with warm water before attaching to infant,. g. Begin with least sore side,

-to soften nipple and remove dried milk -to establish letdown reflex

Assessment
Subjective: tulo kaadlaw na ko walay ligo as verbalized by the patient. Objective: -dirty nails -uncombed hair - Dry skin -Foul Odor Unable to perform ADL without assistance

Nursing Diagnosis
Self-care deficit related to fatigue

Planning
After 4 hours of nursing intervention , the patient will be able to: -perform self care activities within level of activity. -able to perform personal hygiene daily.

Intervention INDEPENDENT: -established rapport -encouraged the patient to have a daily hygiene and explained the important of having a bath everyday -instructed the significant others to assist the patient to perform activities of daily living.

Rationale

Evaluation

-weakness -fatigue -decreased motivation

-to gain cooperation Of the patient

-to promote comfort And good hygiene

-this is to achieve the