SANLORENZO RUIZ COLLEGE

NURSING CARE PLAN

NAME OF PATIENT:FERNANDEZ,GERALDINE
ATTENDING PHYSICIAN:DR.GARDENIA LARRAZABAL ROOM NO:0B1
CHIEF COMPLAINTS: POST-OP: PAIN AT THE WOUND SITE

CUES DIAGNOSIS SCIENTIFIC OBJECTIVE OF INTERVENTION RATIONALE EVALUATION

BASIS CARE
Objective cues: Acute pain Caesarean After 8 hours of Independent: After 8 hours of
Onset of pain related to delivery is the nursing • • nursing
was after the disruption of surgical removal interventions, Evaluate pain Provides interventions, the
delivery.Pain skin, tissue, and of the infant the patient pain regularly noting information patient pain was
was located at muscle integrity from the uterus will be relieved characteristics, about need for or relieved or
the incisional through an or control. location, effectiveness of controlled
area at duration incision made in intensity (0-10 interventions.
of 2-3minutes the abdominal scale).
characterized by wall and the • •
guarding pain at uterus. Size and Identify specific Prevents undue
the incision site, location of the activity strain on
aggravated by incision vary, limitations. operative site.
sudden but abdominal • •
movement and and uterine Recommend Promotes return
relieved by incisions of planned or of normal
resting in choice are low progressive function and
comfortable and horizontal. exercise. enhances
position with a Vertical • feelings of
pain scale of 6 as incisions may be Schedule general well
1 is the lowest necessary for adequate rest being.
ant 10 as the quicker periods. •
highest. procedures, the • Prevents fatigue
-facial grimace presence of Review and conserves
-narrowed focus adhesions and importance of energy for
-guarded other nutritious diets healing.
behavior complications and adequate •
-vital signs as fluid intake. Provides
follows: • elements
T: 37.3 Reposition as necessary for
P: 80 indicated. tissue
R: 18 • regeneration or
Bp: 110/90 Provide healing.
additional •
Subjective cues: comfort May relieve
“sakit akong measures like pain and enhance
tinahian day”as back rub circulation.
verbalized by the • •
patient Encourage use Improves
of relaxation circulation,
technique like reduces muscle
deep breathing tension and
exercises. anxiety
Collaborative: associated with
• pain.
Administer Relieves muscle
analgesics or and emotional
non steroidal tension.
anti- •
inflammatory To relieve mild
drugs as or moderate
prescribed. pain.
 SANLORENZO RUIZ COLLEGE
NURSING CARE PLAN

NAME OF PATIENT:FERNANDEZ,GERALDINE CASE NO:

ATTENDING PHYSICIAN:DR.GARDENIA LARRAZABAL ROOM NO: 0B1

CHIEF COMPLAINTS:PRE-OP:LABOR PAINS

POST-OP:PAIN AT THE WOUND SITE

CUES DIAGNOSIS SCIENTIFIC OBJECTIVE OF INTERVENTION RATIONALE EVALUATION

BASIS CARE
Objective cues: Sleep pattern As soon as after After 8hours of 1.provide calm 1.so that patient After 8hours of
-restlessness disturbance:Difficulty the cesarean holistic nursing and safe will be able to holistic nursing
-tired in falling asleep delivery the care the patient environment relax care the patient
-weak secondary to cesarean women feel will be able to was able to
-dark circle under
delivery exhausted and sleep sufficient 2.advise patient 2.to reduce sleep
the eyes
-vital signs as
pain felt at the amount to feel to use comfort stimulation so sufficiently and
follows incision site,she rested during measure like that patient will feel rested
T: 37.3 experienced the postpartum listening to relax during the
P: 80 some difficulty period by music postpartum
R: 18 in falling asleep having 6-8 period by
Bp: 110/90 because she was hours of sleep 3.obtain 3.to have a having 6-8
unable to find a everyday. feedback from baseline data hours of sleep
Subjective cues: comfortable circumstances that will serve everyday.
“dili manko position on bed from client as your guide
kayo makatog because of the sleeping pattern
day”as post-operative
verbalized by procedure. 4.monitor v/s 4.to assess the
the patient condition of the
patient
5.apply 5.to build trust
therapeutic and rapport and
touch also it will
provide comfort
to the patient

6.place the 6.to minimize

patient in pain felt
comfortable
position

7.administer 7.instruct
medication as patient about
prescribe the action and
side effect of
the drug.
 SANLORENZO RUIZ COLLEGE
NURSING CARE PLAN

NAME OF PATIENT:FERNANDEZ,GERALDINE CASE NO:

ATTENDING PHYSICIAN:DR.GARDENIA LARRAZABAL ROOM NO: 0B1
CHIEF COMPLAINTS:PRE-OP:LABOR PAINS
POST-OP:PAIN AT THE WOUND SITE

CUES DIAGNOSIS SCIENTIFIC OBJECTIVE OF INTERVENTION RATIONALE EVALUATION

BASIS CARE
Objective: Decreased Preeclampsia is a After 8 hours of Independent:
• cardiac output common nursing • •
Variations in related to problem during interventions, Monitor blood Comparison of After 8 hours of
blood pressure. decreased pregnancy. The the patient will pressure of the pressures nursing
• venous return condition — participate in patient. Measure provides a more interventions, the
Edema
sometimes activities that in both arms or complete picture patient was able
•
V/S taken as referred to as reduce blood thighs three of vascular to participate in
follows: T: 37.3 pregnancy- pressure or times, 3-5 involvement or activities that
P: 80 induced cardiac work minutes apart scope of the reduce blood
R: 18 hypertension — load. while patient is problem. pressure or
Bp: 110/90 is defined by at rest, then • cardiac work
high blood sitting, then Presence of load.
pressure and standing for pallor, cool,
excess protein in initial moist skin and
the urine after 20 evaluation. delayed capillary
 weeks of • refill time may
Subjective: pregnancy. Observe skin be due to
“Napansin ko na Often, color, moisture, peripheral
bigla na lang preeclampsia temperature and vasoconstriction
bumigat ang causes only capillary refill
timbang ko” (
modest increases time. •
I noticed that I
gained a lot of in blood • May indicate
weight pressure. Left Note dependent heart failure,
) as verbalized by untreated, or general renal or vascular
the patient however, edema. impairment.
preeclampsia can • •
lead to serious Provide calm, Help reduce
— even fatal — restful sympathetic
complications surroundings, stimulation,
for both mother minimize promotes
and baby environmental relaxation.
activity or noise. •
• Reduces
Maintain physical stress
activity and tension that
restrictions. affect blood
pressure and
• course of
Instruct in hypertension.
relaxation •
techniques, and Can reduce
guided imagery. stressful stimuli,
Collaborative: produce calming
• effect, thereby
Implement reduce blood
dietary sodium, pressure.
fat, and
cholesterol •
restrictions as These
indicated. restrictions can
help manage
fluid retention
and with
associated
hypertensive
response, which
decrease cardiac
workload.