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Dependent:
Objective:
V/S
T: 36.2 C / axilla
RR: 25, regular
PR: 88, regular
BP: 140/90 mmHg
Guarding
behavior in
the RUQ of
the
abdomen
Facial
grimacing
Irritability
LAB
ALT: 74 U/L
AST: 76 U/L
Assessment Diagnosis Scientific Planning Implementation Rationale Evaluation
Explanation
Subjective: Acute pain Abnormal Short Term: Independent: Short Term:
“Masakit yung tahi related to post- placentation
ko lalo na kapag op surgical After 30 minutes to 1 a.) Check patient’s V/S. - Can be altered when After 30 minutes to 1
gumagalaw ako. incision hour of nursing the patient is in pain hour of nursing
hindi ako secondary to Low prefunded intervention, the patient b.) Assess patient’s general - To note for any intervention, the goal
komportable.” – as Pre-eclampsia placenta will be able to; physical condition. abnormality. was met as
verbalized by the c.) Listen and respect - Helps in alleviating evidenced by the
patient. Verbalize client’s expression about anxiety and refocusing patient;
Release of cytokines nonpharmacolo his condition. attention.
Character: and other toxins gical methods Verbalized
Sharp pain that provide d.) Monitor patient’s pain - To rule out worsening nonpharmacol
relief. and note/investigate of underlying condition or
ogical
Onset: Vasoconstriction and Follow changes from previous development of
methods that
Post- platelet activation prescribed reports. complications.
Operation pharmacological provide relief.
(January 21, regimen. e.) Perform a - Pain is a subjective Followed
2019) Generalized Demonstrate comprehensive experience and must be prescribed
Location: endothelial and use of relaxation assessment of pain to described by the patient pharmacologic
Pain from vascular dysfunction skills and include location, in order to plan effective al regimen.
incision characteristics, onset, treatment.
diversional Demonstrated
duration, frequency,
Impact on fetus: activities, as quality, intensity, and use of
Duration:
indicated, for relaxation
Continuous undernutrition precipitating factors of
pain and because of utero- individual pain. skills and
getting placental vascular situation. f.) Promote adequate rest, - To prevent fatigue and diversional
worse when insufficiency Report pain is and provide comfort promote non- activities, as
moving, or relieved or measures (e.g. touch, pharmacological pain indicated, for
doing reduced. repositioning, nurse’s management.
individual
physical Growth restriction to (From pain scale of presence), quiet
fetus that may cause environment. situation.
activities 7/10 down to 5/10)
such as distress g.) Instruct, or encourage - Helps reduce pain and Report pain is
walking. use of breathing promote relaxation. relieved or
relaxation exercise reduced.
Severity: Age related: h.) Encourage diversional - To distract attention or (Pain scale of
Using the Possible activities such as divert focus from pain. 5/10)
Universal complication listening to music and
Pain socializing with others.
Assessment
Tool, the Stabilized mother Dependent:
scale is and baby
6/10- i.) Administer pain reliever - Pharmacological
Moderate; medication as ordered management to reduce
Interferes Elective Surgery/CS by the physician. pain.
her
concentratio (Celecoxib 200mg tab BID)
n, and felt Tissue
uncomfortab Injury/Inflammatory
le Cell
Pattern:
Moving Sense by Nociceptor
makes it
worse, and
relieved, Converted to electro
when lying chemical signals
on bed and
controlled
when given Transmitted to spinal
pain cord by Dorsal Root
medication. Ganglia and then to
the Brain
Associated
factors:
The pain affects: Acute Pain
“Hindi kasi
ako
masyadong
makatulog
dito sa
hospital at
nararamdam
an ko pa rin
yung sakit
dito sa tyan
ko kapag
gabi lalo
kapag
gagalaw
ako, hindi
ako
komportable
.”
20-25
minutes of
sleep
disturbance
(total 4hrs of
sleep with
interruption)
Objective:
V/S
T: 36.7 C / axilla
RR: 16, regular
PR: 86, regular
BP: 120/90 mmHg
Surgical
incision of
13cm long
and 15
stitches (low
transverse)
Guarding
behavior on
the
abdomen
Positioning
(to avoid
pain)
Facial
grimacing
Irritability
Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation
Explanation
Subjective: Impaired skin Surgical Short Term: Independent: Short Term:
integrity related intervention (CS)
“Inoperahan ako to post-surgical After 6-8 hours of After 6-8 hours of
a.) Support and instruct
kaninang umaga.” – incision nursing intervention, - Reduces possibility of nursing intervention,
patient in incisional
as verbalized by the the patient will be able support when turning, dehiscence and the goal was met as
patient. Incision on the to; coughing, deep incisional hernia. evidenced by:
lower abdomen breathing and
(low transverse) Have reduced ambulating. Reduced risk of
Objective: risk of further b.) Observe incision - Verifies status of further
impairment of periodically, noting healing, provides for impairment of
approximation of
V/S skin integrity. early detection of skin integrity.
wound edges,
T: 36.7 C / axilla Surgery involves Demonstrate hematoma formation developing complications Demonstrated
RR: 16, regular cutting/ understanding and resolution, and requiring prompt understanding
PR: 86, regular penetration of and ability to presence of bleeding evaluation and and ability to
BP: 120/90 mmHg care for and drainage. influencing choice of care for
skin surface and
skin layers infection-prone intervention. infection-prone
Surgical site. - Promotes healing. site.
incision of c.) Provide routine
incisional care, being Accumulation of Demonstrated
13cm long Demonstrate
and 15 careful to keep serosanguineous ability to
Impaired skin ability to
stitches (low dressing dry and drainage in perform
integrity perform
transverse) sterile. Assess and subcutaneous layers hygienic
hygienic
Intact maintain patency of increases tension on measures like
measures like
dressing drains. suture line, may delay proper hand
proper hand
washing and wound healing, and washing and
body hygiene. serves as a medium for body hygiene.
bacterial growth.
Long term: - Reduces pressure on Long term:
d.) Encourage frequent
After 3 days of nursing positional changes, skin, promoting
After 3 days of nursing
intervention the patient inspect pressure peripheral circulation and intervention the goal
will: points, and massage reducing risk of skin was met as evidenced
gently, as indicated. breakdown, Skin barrier by the patient:
Experience Apply transparent skin
healing of reduces risk of shearing Experienced
barrier to elbows and
wound/incision heels, if indicated. injury. healing of
and regain skin e.) Encourage intake of - Help boost and support wound/incision
integrity protein-rich and calorie- the immune system and regain skin
Reduce risk for rich foods. responsiveness. integrity
infection f.) Emphasize the - It serves as a first line Reduced risk
importance of proper defense against infection for infection
hand/body hygiene
and minimizes the risk of
techniques. Practice
proper hand hygiene contamination and
and teach the patient development of infection.
and SO to do so.
g.) Maintain aseptic - Aseptic technique
technique with any decreases the chances
procedures. Provide of transmitting or
routine wound care, as
spreading pathogens to
appropriate.
the patient.
Dependent:
(Co-amoxiclav 325 mg 1
tab OD)
Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation
Explanation
Subjective: Risk for Spiral artery Short Term: Independent: Short Term:
bleeding related doesn’t widens
“Medyo okay na pero to decreased Within the 8 hours a) Assess and monitor - Increased heart rate
vital signs. Within the 8 hours shift,
nanghihina parin platelet count shift, the patient will and orthostatic changes
ako.” – as verbalized be able to: accompany bleeding. the goal was met as
Less blood gets evidenced by the
by the patient. in the placenta b) Assess patient’s - Bleeding maybe
patient:
general condition and obvious
Identify check for any signs of (bruises/petechiae
individual risks Identified
Objective: bleeding. epistaxis, bleeding gums, individual risks
Hypo-perfused and engage in
appropriate abdominal pain, and engage in
placenta releases appropriate
V/S behaviors to hematemesis, melena,
pro inflammatory behaviors to
T: 36.7 C / axilla proteins prevent or hematuria).
reduce prevent or
RR: 16, regular c) Check and monitor - To rule out worsening
frequency of reduce
PR: 86, regular laboratory results of underlying condition or frequency of
BP: 120/90 mmHg bleeding especially the platelet development of
episodes. bleeding
count, PT, Hgb, and complications. episodes.
Weak-looking Pro inflammatory Be free of signs Hct.
of bleeding Free of signs of
Pale proteins goes to d) Maintain safe bleeding
environment for the - To prevent injury and
palpebral mother circulation
conjunctiva Long term: patient. promote rest and
Long term:
comfort.
After 3 days of nursing After 3 days of nursing
LAB e) Explain the different - For the patient to intervention the goal
intervention the patient risks for bleeding.
Platelet count: 90 x become knowledgeable was met as evidenced
Pro inflammatory will: f) Explain the different
10 9/L about the disease by the patient:
proteins causes factors to prevent
Hgb: 116 g/L Maintain process.
vasoconstriction bleeding. Maintained
Hct: 33% reduced risk of
g) Restrain patient from reduced risk of
Prothrombin time: bleeding as any activities that could
evidenced by bleeding as
20.7 seconds cause bleeding. evidenced by
Prolonged normal platelet
normal platelet
vasoconstriction count and
damages clotting times Dependent: count and
endothelial cell and factors h) Administer appropriate - For pharmacological clotting times
within normal medications as ordered management and factors
range. by the physician. within normal
(coagulation)
range.
Formation of i) Transfused PRBC if - To restore Hgb/Hct
thrombi (body will prescribed. level and to replace (Platelet count: 158 X
use massive blood lost. 10 9/L
amount of Collaborative: PT: 12 seconds)
platelets) j) Communicated need - To assure availability
for platelet support to and readiness of
transfusion center.
platelets when needed.
Blood clots
blocks RBC
RBC gets
destroyed
(hemolysis)
Collaborative:
j.) Refer to sleep - For specific
specialist for treatment interventions and/or
when indicated. therapies.