CUES

Subjective: masakit pa tak tinahian as verbalized by patient. Objective: Facial mask of pain. Guarding behavior. Narrowed focus. V/S taken as follows: T: 36.4 P: 86 R: 20 BP: 110/70

NURSING DIAGNOSIS
Acute pain related to disruption of skin tissue, and muscle integrity secondary to CS

RATIONALE
Caesarean delivery is the surgical removal of the infant from the uterus through an incision made in the abdominal wall and the uterus. Size and location of the incision vary, but abdominal and uterine incisions of choice are low and horizontal. Vertical incisions may be necessary for quicker procedures, the presence of adhesions and other complications.

GOAL OF CARE
After 2 hours of nursing interventions, the patient pain will be relieved or controlled.

NSG. INTERVENTION

RATIONALE

EVALUATION

Independent: Evaluate pain regularly noting Provides information characteristics, location, about need for or effectiveness of intensity (0-10 scale). interventions. Identify specific activity limitations. Recommend planned or progressive exercise. Prevents undue strain on operative site. Promotes return of normal function and enhances feelings of general well being. Prevents fatigue and Conserves energy for healing. Provides elements necessary for tissue regeneration or healing. May relieve pain and enhance circulation. Improves circulation, reduces muscle tension and anxiety associated with pain.
Relieves muscle and emotional

Schedule adequate rest periods.

Review importance of nutritious diets and adequate fluid intake. Reposition as indicated.

Provide additional comfort measures like back rub. Encourage use of relaxation technique like deep breathing exercises.

tension.

Collaborative: Administer analgesics or non steroidal anti inflammatory drugs as prescribed. To relieve mild or Moderate pain.

CUES
Subjective: nahadlok ak ma impeksyon tak samad, kay mahugaw dinhi tas sarahid la kami hit mga higdaan as verbalized by the patient.

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

RATIONALE
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

RATIONALE

EVALUATION

-To establish a baseline data

-Inspect dressing and perform -Moist from drainage can be wound care a source of infection - Monitor white blood count - Rising WBC indicates bodys efforts to combat pathogens; normal values: 4000 to 11,000 mm3 -these are signs of infection

Objective: - dressing dry and intact follows: T: 36.4 P: 86 R: 20 BP: 110/70

- Monitor Elevated temperature, Redness, swelling, increased pain, or purulent drainage at incisions - Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient.

-Friction and running water effectively remove microorganisms 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).

- 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.

- 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 pathogens

Dependent: - Administer antibiotics

CUES

NURSING DIAGNOSIS

RATIONALE

PLANNING

INTERVENTIONS
INDEPENDENT

RATIONALE

EVALUATION

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

Risk for constipation r/t post pregnancy 2 cesarean section

If a mother has an episiotomy (repair of torn rectal tissue), having a bowel movement can be very painful, and she may unconsciously hold on to her stool. Also, after a cesarean section delivery, the bowel can be temporarily paralyzed.

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

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

This is to determine the normal bowel pattern

To increase the bulk of the stool and facilitate the passage through the colon To promote moist soft stool

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

Long Term Goal: Within 3 days of nursing interventions, the patient will be able to maintain usual pattern of bowel functioning

To stimulate contractions of the intestines and prevent post operative complications To avoid stress on the cesarean incision/ wound

However, since she has had cesarean, also encourage adequate rest periods

COLLABORATIVE: Administer bulk-forming agents or stool softeners

To promote defecation

such as laxatives as indicated or prescribed by the physician

CUES

NURSING DIAGNOSIS

RATIONALE

PLANNING

INTERVENTIONS
Independent

RATIONALE

EVALUATION

Subjective: diri pa gud tuhay nga naka.suso tak baby as verbalized by the patient Objective: >the baby doesnt respond to other comfort measures given by the mother

Breastfeeding, ineffective r/t unsatisfactory feeding process

Inability to demonstrate proper breast feeding technique

(STG) After 8 hours of Nursing Intervention, the baby will be able to stop crying ad will show satisfactory response to breastfeeding process (LTG) After a couple of months of Nursing Intervention, the baby will gain weight and will receive adequate amount of milk supply.

>Explain the benefits of breast feeding, the mechanisms involve in lactation, the proper breast care and most especially the proper breast feeding position. >Assist the breastfeeding process as needed > Increase fluid intake

>to promote breast feeding because breast milk contains all the necessary nutrients a baby needs for the first 6 months of life

>to promote bonding between mother and child >Breastfeeding delays ovulation and therefore the possibility of another pregnancy >Breastfeeding helps stop bleeding after delivery

>Discuss the importance of adequate nutrition during lactation

CUES

NURSING DIAGNOSIS

RATIONALE

PLANNING

INTERVENTIONS
Note clients level of consciousness/mentation Note current intake/type of diet such as NPO Assess hourly intake and output. Assess VS and note changes.

RATIONALE
Evaluate ability to express needs This can negatively affect fluid intake Ensure accurate picture of fluid status Identify changes and therapeutic effectiveness For replacement of fluid

EVALUATION

Objectives: Pale and Cool Skin Body Weakness BP - 110/70 mmHg HR 86 bpm RR 20 bpm Temp 36.4C

Fluid Volume Deficient r/t Active Blood Loss as manifested by pale and cool skin

Greater than a 10% decrease in the prenatal hematocrit is another means used to suggest that PPH has occurred; this value needs to be used cautiously because hematocrit is affected by factors other than blood loss, such as dehydration.

Short term: After 2 hours of nursing intervention, urine output will increase to 30ml/hr from15ml/hr Long term: After 8 hours of Nursing intervention, Patient will demonstrate behaviors or lifestyle changes to prevent development of this situation

Initiate IV fluids/blood transfusion as ordered (specify fluid type and rate) Position patient in supine with hips elevated if ordered Provide emotional support

Position decreases pressure Support and information decrease anxiety

Proper diet and Increase fluid (2-3L/day) and vitamins replace nutritional food rich in iron and vitamin C nutrient losses