Name and Age: Carolyn Melu, 33 years old Room and Bed No./Ward/Institution: 444 St.

d No./Ward/Institution: 444 St. Luke’s Ward, San Pedro Hospital

Reason for Admission: 1 day post LCTS II to an alive baby girl Attending Physicians: Dr. Garado

Date/
T
i Cues Needs Nursing Diagnosis Objectives Nursing Interventions Evaluation
m
e
S: “ Maglisud ko ug lihok- A Impaired physical At the end of 1) Establish rapport, monitor vital signs and
05/20/05 lihok kay wala pa ko kaayo’y C mobility r/t my 7-hour do preliminary assessment. 05/20/05
@ kusog.”, patient verbalized. T decreased muscle span of care, ® Rapport between the nurse and the patient @
8:00 am I strength and my patient will makes nursing procedures easy to do; vital 3:00 pm
O: V discomforts in using be able to signs serve as a baseline data; physical
> 1 day post Low Cervical I full range of motion improve assessment helps detect presence of Goal met.
Transverse Cesarean Section T 2° to LCTCS physical abnormal findings and untoward signs and
II Y ® A Low cervical mobility as symptoms. After my 7-hour
> reluctance to attempt - transverse cesarean evidenced by: 2) Evaluate/monitor continuously the degree course of nursing
movement noted E section is a kind of a) willingness of the pain in the incision site. care, the patient
> on clear liquids diet X cesarean operation to attempt ® Level of activity/exercise is dependent on was able to
> with abdominal binder and E and an abdominal movement; progression/ resolution of inflammatory improve physical
contour brief R surgery as well b) ability to process. mobility as
> with fair capillary refill time C causing initiation purposely 3) Maintain bed/chair rest when indicated. manifested by:
of 2-3 seconds and fair skin I and perpetuation of move within Schedule activities providing frequent rest a) being
turgor S inflammatory the physical periods. willing to
> with promote early E responses with the environment; ® Systemic rest is mandatory during acute initiate range
ambulation order help of immunologic c) increased exacerbations and important throughout all of motion
> with IVF of D5LR1L received P mechanisms. The muscle phases of disease to prevent fatigue, activities such
at 800 cc level infusing well at A after-effects of strength and maintain strength. as going into
right metacarpal vein T surgery thus include function of 4) Assist active/passive range of motion as the CR with
regulated at 35 gtts/minute T pain, physical affected and/or well as resistive exercises and isometrics watcher’s
> with meds: Cataflam, E discomforts, limited compensatory when able. assistance;
Kalium durule, Tramadol, R range of motion, and body part as ® Maintains/improves muscle strength and b) tolerance
Pacreatin N decreased muscle verbalized; general stamina. Inadequate rest leads to to move self
strength. d) demonstra- long inflammation duration, whereas within the
Bibliography: tion of excessive activity can damage the muscles. room and at
• Smeltzer, techniques and 5) Reposition frequently. Demonstrate/assist the bedside;;
Suzanne, RN. behaviors that with transfer techniques and use of mobility c) Verbalize
Medical- enable aids. d, “Mas
Surgical resumption/ ® Relieves pressure on tissues and promotes makalihok
Nursing. continuation of circulation. Facilitates self-care and nako karon
Lippincott activities. patient’s independence. Proper transfer kaysa ganiha.”
Williams and techniques prevent shearing abrasions of d) Used IV
Wilkins. © 2004. skin. post and with
10th Edition 6) Position with pillows on bed. watcher’s
® Promotes body stability (reducing risk of support, as a
injury) and maintains proper position and supportive
body alignment, minimizing contractures. device in going
7) Suggest using small/thin pillow under into the
neck. comfort room.
® Prevents flexion of neck.
8) Encourage patient to maintain upright
and erect position when sitting, standing, Evaluated by:
and walking.
® Maximizes muscle function, maintains
mobility. Novie Jay D.
9) Discuss/provide safety needs, e.g., raised Onor, St.N.
chairs/toilet seat, use of handrails in
tub/shower and toilet, proper use of mobility
aids/wheelchair safety.
® Avoids accidental injuries and falls.
10) Encourage increasing oral fluid intake to
at least 3L per day so that she can urinate to
at least 2 L per day.
® Prevents the formation of renal calculi.
12) Provide foam/ alternating pressure
mattress.
®Decrease pressure of fragile tissues to
reduce risks of immobility/ development of
decubitus ulcers.
13) Do alternating warm and cold compress.
® Promotes faster healing of the muscles.
14) Administer medications as indicated.
dminister medications as indicated.
• Cataflam (Diclofenac sodium)
® Helps prevent fever recurrence and
treatment for mild-moderate pain.
Prevents inflammatory processes from
becoming severe.
• Tramadol
® Decreases edema and pressure on the
nerve root(s).
• Pacreatin
® Aids in the digestion of CHON and
carbohydrates.
• Kalium durule
® Prevents the occurrence of
hypokalemia when food intake is
inadequate.
 Criteria:

Nursing Care Plan Promptness

Date & cues
5%____
10%____
Needs 10%____
Nursing
Diagnosis 15%____
On Objectives
of care 10%____
Nursing
Intervention
s 40%____
Evaluation 5%____

Primary Nursing Bibliograph

y 5%____

In partial fulfillment
of the requirements in
NCM 104 RLE

Submitted to:

Michelle Theresa Jimenez, RN

Clinical Instructor

Submitted by:

Novie Jay D. Onor, StN

BSN 4B, Group 3

21 June 2005