Nsg Dx #2: Risk for infection r/t post

surgical procedure secondary to presence Nsg Dx #3: Risk for imbalanced fluid
of contraptions volume r/t decrease in normal urine
output
Objective cues: Initials: S.DT.L
Patient’s Medical Diagnosis: Low Transverse Cesarean section 1ْ
- 30 years old Objective cues:
oligohydramnios
- G1P1 (1001) - Vital signs: temperature - 37ْ C, PR –
- Vital Age:
signs:30temperature
years old - 37ْ C, PR – 82Gender: Female 82 bpm,ofRR
Basis for prioritization: Maslow’s Hierarchy – 18 cpm, BP – 100/70
needs
bpm, RR – 18 cpm,
Category: I BP – 100/70 mmHg Room no.: 609B Date admitted: July 23, 2009 mmHg
Student nurse: Valdez, Katrine
- (+) Foley catheter - total urine output: 160ml
- (+) IV Fluid and side drip - (+) Foley catheter
- Lochia: red, (-) foul odor - Diet is NPO
- (+) abdominal incision MDx: Low Transverse Cesarean section 1ْ - (+) IV fluids
- (-) fever oligohydramnios

Priority Assessment:

o Vital signs
o Age
o OB history
o Nutrition and Diet
o Skin Condition
Nsg Dx#4: Risk for constipation r/t
Nsg Dx #1: Impaired skin integrity r/t o Vaginal Discharge insufficient physical activity
surgical procedure aeb presence of o Contraptions
abdominal incision o Intake and output Objective cues:
o Activity - Vital signs: temperature - 37ْ C, PR –
Objective cues: o Bowel Movement 82 bpm, RR – 18 cpm, BP – 100/70
- 30 years old mmHg
- Vital signs: temperature - 37ْ C, PR – 82 - (+) flatus
bpm, RR – 18 cpm, BP – 100/70 mmHg - (-) Bowel movement
- G1P1 (1001) - Diet is NPO
- (+) abdominal incision - Limited ROM
- Skin is rarely moist
- Limited ROM