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ASSESSMENT NURSING RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired Caesarean delivery Short Term: Independent: Short Term:
“Makulog ang skin and is the surgical After 6-8 hours of  Keep the area clean and dry  Moisture harbors After 6-8 hours of
tinahian sako.” As tissue removal of the nursing bacteria and other nursing
verbalized by the pt. integrity r/t infant from the interventions of pathogens inducing interventions of
post surgical uterus through an nursing infection on the site nursing
Objective: procedure as incision made in the interventions,  Change dressing every 24  Proper wound care interventions,
 Vertical incision site manifested abdominal wall and the client will: hours promotes wound the client:
on abdominal area by vertical the uterus. Size and  Have reduced healing; a new and dry  Has reduced risk of
incision site location of the risk of further dressing prevents further impairment of
 Wound measures 9 on abdomen incision vary, but impairment of infection skin integrity
cm abdominal and skin integrity  Provide a splinting pillow  Splinting provide a  Wound is dry
uterine incisions of  Patient’s support to the area  Dressing is dry and
 with surgical choice are low and caregivers will minimizing discomfort intact
dressing on horizontal. Vertical demonstrate and preventing the site  Wound measures
hypogastric area of incisions may be understanding & to reopen not more than 9 cm
her abdomen; dry necessary for skill in care of  Inspect the incision every  Frequent assessment  Pt relays reduced
and intact quicker procedures, wound shift using REEDA (redness, can detect early signs pain
the presence of edema, ecchymosis, and symptoms of  Patient’s caregivers
 guarding behaviour adhesions and other Long Term: discharge, and infection demonstrated
during changing of complications. After 3-4 days approximation) understanding & skill
dressing of nursing  Inform patient of the in care of wound
interventions, purpose of self-care  This may promote the  Verbalizes
 pain scale = 5 the client will be practices compliance of the understanding of
able to display patient to wound care the importance of
 narrowed focus improvement in activities proper wound care
wound healing as  Use appropriate barrier  To protect wound and or after health
 V/S taken as follows: evidenced by: dressings, wound coverings, the surrounding area teaching
 Dry and intact drainage appliance and skin  Identifies principles
T: 36.5 dressing protective agents for open of proper wound
P: 76  Absence of wounds care such as proper
R: 18 erythema or  Provide optimum nutrition  Provides a positive handwashing
BP: 100/80 redness including vitamins such as nutrition balance to aid before handling the
 Absence of Vitamins C and E in skin/ tissue healing wound
purulent and maintain general  Identifies proper
discharge good health nutrition as a
 Absence of  Encourages early ambulation  To promote circulation helpful practice to
itchiness or mobilization and reduces risks promote healing
 Absence of associated with
blood oozing immobility Long Term:
on site  Increase protein intake  To promote cell After 3-4 days
regeneration of nursing
 Educate client and relatives  Educating the client and interventions,
on signs and symptoms of her family extends the the client will be able to
infection and when to call nursing care to their display improvement in
the agency or physician with home; early assessment wound healing as
concerns and intervention help evidenced by:
prevent serious  Dry and intact
problems from dressing
Collaborative: developing  Absence of erythema
 Administer prophylactic or redness
antibiotics as prescribed:  Inhibits synthesis of  Absence of purulent
Cefuroxime (Zegen) 500 mg bacterial cell wall discharge
1 cap TID causing bacterial cell  Absence of itchiness
Diclofenac Sodium 750 mg IV death which prevents  Absence of blood
 Administer Methergine 200 infection oozing on site
mg IV PARTIALLY MET
 Promotes uterine
contraction thus
promotes healing and
prevents bleeding