Name: Lora F.

Aquino Date:01/20/2020 Week: 2

NCP # 1 (must choose one care plan from each area – L&D, Antep, PP, Nsy, NICU)

WEEKLY PLAN OF CARE – Nursing 314

1. The area I worked today: Post Partum Unit

2. Name of the RN I worked with today: Judy

3. Select ONE client from your list today. List 2 nursing diagnosis (actual or potential problems),
prioritize them, give the etiology and make a plan of care for this specific client. Problems may be
Physical, Social support, Emotional concerns, Psychological issues, Developmental stage, and Spiritual
needs. Include evidence-based resources such as – Elsevier, LLUCH policies and protocols, and
ACOG/AWHONN standards as related to your clients’ problems and interventions.

Prioritized Problem Etiology (cause) of the Problem
using accepted Nursing
Diagnosis format
1. Acute Pain r/t surgical
incision secondary to A cesarean birth, often called a C-
Cesarian Section as section, is the delivery of the baby
evidenced by facial through incisions in the mother’s
grimacing and pain scale abdomen and uterus. Cesarean
of 5/10 deliveries, whether elective or
medically necessary, have risen
dramatically in recent decades in
the United States, making
evidence-based research on
methods, postoperative care, and
how to safely reduce their
incidence all the more imperative.
Ob-gyns, physicians whose
primary responsibility is women’s
health, are best suited to help
women determine whether
cesarean delivery is appropriate
for their pregnancy. -
https://www.acog.org/Womens-
Health/Cesarean-
Delivery?IsMobileSet=false
Pain is defined as unpleasant
sensory and emotional experience
arising from actual or potential
tissue damage (C-section incision)
or described in terms of such
damage. (International Association
for the Study of Pain);
(Nurse’s Pocket Guide)
Plan of Care (Interventions) you should do
to bring your client to wellness.
Assess location, nature, and duration of
pain, especially as it relates to the indication
for cesarean birth. -Indicates the suitable
choice of treatment. The patient awaiting
imminent cesarean birth may encounter
varying degrees of discomfort, depending
on the indication for the procedure.
Lessen or completely remove anxiety-
producing circumstance such as too much
visitors, give accurate information. Levels
of pain tolerance are individual and are
affected by various factors. Extreme
anxiety following an emergency situation
may develop discomfort due to fear,
tension, and pain affecting the patient’s
ability to cope
Educate proper relaxation techniques;
position for comfort as possible.- May help
in decreasing anxiety and tension, promote
comfort and enhance sense of well-being.
Administer medications such as sedative,
narcotics, or preoperative drugs as ordered.
-Promotes comfort by blocking pain
impulses. Potentiates the action of
anesthetic agents
Monitor VS noting increase in temperature
and pulse. Increase in vital signs may
indicate increasing pain or occur in
response to fever and inflammatory
 process. Fever may contribute to general
discomfort.

2. Risk for infection Skin is the body’s first line of
related to mechanical defense against foreign materials
trauma of surgical that can be considered as injuring
incision of the skin and agents. Once the skin is disrupted,
subcutaneous tissue this will put a person at risk since
secondary to Cesarean it may become a good medium for
section bacterial growth. Cesarean section,
like any other surgical procedures,
includes invasion of the inside
body, specifically the skin and
subcutaneous area.
(NANDA 9th edition.pp 461-465)
(Med-Surgical Nursing, Black and
Hawks 8th Edition pp 952-954)
Assess the overall condition of the skin.
Assessment of the condition of the skin
provides baseline data for possible
interventions for the nursing diagnosis
Reinforce initial dressing and chage as
indicated. Protects wound from mechanical
injury and contamination which may cause
an infection.
Assess amounts and characteristics of
drainage.-Decreasing drainage suggests
evolution of healing process, whereas
continued drainage or presence of bloody or
odoriferous exudate suggests
complications

Encourage client to demonstrate good skin

hygiene, e.g., wash thoroughly and pat dry
carefully after teaching. -Maintaining
clean, dry skin provides a barrier to
infection. Patting skin dry instead of
rubbing reduces risk of dermal trauma to
fragile skin

DEPENDENT
Medication such as antibiotics

COLLABORATIVE
Provide optimum nutrition such as increased
protein intake.

4. What nursing interventions were you able to do for this client today? Did it work? Why or Why not?
Problem 1 & 2 (Did your interventions work? Why/why not?)
Patient L.V. came into LLUCH and delived via C/S on 1/17/20. Patient has been receiving care from
Dr.X. Patient pressed the call light and complained of pain on her incision site rating it 5/10, 10 being
the highest. V/S BP 129/72, P 75, RR 19, T 97.7. Upon assessing site, noted no signs and symptoms of
infection. Patient was given Norco 5/325 PRN for pain and upon reassessing after 30 mins, resident
stated “It helped a lot” with a pain scale of 0/10, 10 being the highest. Patient was about to be discharged
in the late afternoon so I educated her about relaxation techniques and proper hand washing to prevent
infection. Educated about the signs and symptoms of infection and to increase protein and fluid intake.
Resident verbalized understanding and was able to demonstrate it to me. Patient again asked assistance
 later that day to go to the bathroom and noted that she finished her iced water given an hour before and
after using the restroom, patient did proper hand hygiene. The intervention and teaching was met.1qac

5. What cultural, developmental, or spiritual assessments did you assess that would affect your client’s
plan of care?

There were no challenges I experienced when I was caring for the mother, however when I was
changing the diaper of the baby, I noticed that the cord stump was completely covered with a diaper, I
thought it was just a coincidence so I cleaned the baby and changed the diaper and folded the top part of the
front so the umbilical stump wont be covered, the mother told me not to do that because according to the old
grandmas in their culture, the air will go inside the baby’s stomach through the stump and will make the
baby gassy. I advised her that the best way to care for the stump is to keep it dry, clean and exposed as
possible and covering it with something might cause an infection, the mother was very understanding and
didn’t want to compromise her baby’s health so in the end she let me fold the diaper.

6. What preventive and health promoting education were you able to give your client today? (For
NICU/Nursery clinicals please state the education you taught the parents or care givers if they were there)
My preceptor asked me to check the input and output of the baby, I have noticed that she has been feeding
the baby the baby a full bottle (2oz) and letting it sleep for 5-6 hours. I encouraged the mother that for the
first few days of life the baby’s stomach is almost like the size of the cherry and needs to be fed every 2 to 3
hours. Once the baby’s stomach grows and she starts to gain weight, the feeding interval can move to every
3-4 hours. The patient was hesitant at first to believe me but after showing her pictures on google and my
preceptor backing me up, she was thankful for the information and the next time I checked on her baby’s
I&O, she has been feeding th baby every 2-3 hours.

7. One of the objectives of this clinical is to be able to utilize EBP resources to widen your knowledge about
your client’s condition and care. List 2 resources used to assist you in planning the care of your client? (Can
use protocols, clinical practice guidelines, Elsevier. etc)

A. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-
Obstetric-Practice/Postpartum-Pain-Management?IsMobileSet=false

B. https://www.apsf.org/article/preventing-surgical-site-infection-after-cesarean-delivery-the-
anesthesia-professionals-role/

8. What was the highlight of your day?

The highlight of my day was following my preceptor and reminding me how nursing should be done.
She was behind on passing meds and charting however she takes her time giving the appropriate care and
information to every patient she has. One patient she has was very thankful to her upon discharge because
she prayed over them and that was a very nice gesture extending your faith and kindness.

9. What concerns or questions do you have for your clinical instructor?

None at the moment.

Revised 1/2019