\

NURSING CARE PLAN

ASSESSMENT Subjective: Sumasakit ang sugat ko. Objective: >Facial grimace >Pain Scale 6/10. >Guarding behavior irritablity

DIAGNOSIS > Pain related to surgical incision.

SCIENTIFIC EXPLANATION >Cesarean birth is a birth of a fetus through a transabdominal incision of the uterus. The purpose of a cesarean birth is to preserve the life and health of the mother and the fetus; it may be the best choice when there is evidence of a maternal and fetal complications. > The womans physiologic concerns for the first few days may be dominated by the pain at the incision site and the pain resulting from intestinal gas and hence the need for pain relief.

PLANNING > After 8 hours of nursing intervention the patient will be able to verbalize the relieve of pain. > The patient will appear relax able to sleep/ rest and participate in activities appropriately.

INTERVENTION > Render morning care

RATIONALE > Enhance proper hygiene

EVALUATION > After 4 hours of nursing intervention, the goal was partially met: -the patient verbalized the decreased intensity of pain from 6/10 to 4/10.

> Turn to side every 2 hours. > Assist to set up on bed

>Prevent pulmonary disorder >To promote optimal level of function and prevent complications. > to promote non pharmacological pain management.

> Provide comfort measures (quiet environment) and divertional activities. (focused breathing) > Give pain medications as prrescribed.

> To aid in lowering the intenstity of the pain felt by the patient after surgical incision.

NURSING CARE PLAN

ASSESSMENT S> O>mucous membranes slightly dry >furrows on tongue >decreased salivation >skin dry with poor turgor or pale.(>2seconds capillary refill)

DIAGNOSIS >risk for deficient Volume related to decreased/restricted intake.

SCIENTIFIC EXPLANATION >Body fluid is composed primarily of water and electrolytes. The body is equipped with homeostatic mechanism to keep the composition and volume of body fluids within narrow limits. Organ involved in this mechanism include the kidneys, lungs, heart, blood vessels, adrenal glands, parathyroid glands, and pituitary gland. Body fluid is divided into two types: intracellular (within the cells) and extracellular (interstitial or tissue fluid, intravascular or plasma, and trascellular, such as cerebrospinal or synovial fluids.

PLANNING >Demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output, absence of vomiting.

INTERVENTION >Weigh daily and monitor trends. >Maintain accurate I & O record.

RATIONALE >Weight helps to assess fluid balance. >Accurate records are critical in assessing the patients fluid balance. >Vital sign changes such as increased heart rate, decreased blood pressure, and increased temperature indicate hypovolemia. > encourage her oral intake of fluids as tolerated, again to replace lost volume. >has signs of severe fluid volume deficit. She will probably require intravenous replacement of fluid. This is especially true because her oral intake is decreased/limited..

EVALUATION

>After 8 hours of
proper nursing intervention the patients Maintain fluid volume at functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill.(<2seconds capillary refill).

>Monitor vital signs as appropriate.

>Give fluids as appropriate.

Administer IV therapy as prescribed.

NURSING CARE PLAN

ASSESSMENT Subjective: natatakot na kong mabuntis ulit. Objective: >restlessness >appears tensed and nervous >apparent worry is noted >RR is elevated RRCR TEMPBP-

DIAGNOSIS Anxiety and fear may be related to threat of death and possible loss of ability to conceive.

SCIENTIFIC EXPLANATION >Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger.It is an altering signal that warns of impending danger and enables the individual to take measure to deal with threat.

PLANNING >after 8 hrs of nursing intervention the patient will report reduced anxiety.

INTERVENTION >established rapport >monitor VS >identify client perception of threat

RATIONALE >obtain cooperation >to obtain baseline >to assist patient in identifying feelings and to begin to deal with problems. >to present reality and provide facts.

EVALUATION After 8 hrs. of nursing intervention the patient reported reduced anxiety as evidenced by stable vital signs and maintenance of calmness.

>provide accurate information regarding situation >identify what patients has done previously to cope with anxiety.

>to incorporate previous techniques the client has used that has proven effective.