INTRODUCTION
A case of a 28 year old female, a resident of Marikina City, who was admitted in Melverey Maternity Hospital on May
19, 2014at 8:00 in the morning, with the initial diagnosis of G 2P1(1001) pregnancy uterine 36-37 weeks Age of
Gestation. She was transferred to the Operating Room and had a caesarean section by the doctor. She was also given
spinal anesthesia at 6:01 pm and the operation started at 6:04pm. The procedure lasts for 49 minutes and delivered an
alive baby girl at 6:53 pm together with the placenta and the operation ended at exactly 7:03 pm.
A Cesarean section (C-section) is surgery to deliver a baby. The baby is taken out through the mother's abdomen. In the
United States, about one in four women have their babies this way. Most C-sections are done when unexpected problems
happen during delivery. These include: Health problems in the mother ,The position of the baby, Not enough room for the
baby to go through the vagina, Signs of distress in the baby, C-sections are also more common among women, carrying
more than one baby. The surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also
takes longer to recover from a C-section than from vaginal birth. After healing, the incision may leave a weak spot in the
wall of the uterus. This could cause problems with an attempted vaginal birth later.
Cesarean Section is a surgical procedure in which incisions are made through a womans abdomen and uterus to deliver
her baby. The most common reason that a caesarean section is performed (35% of all cases according to the United States
Public Health Service) is that the woman has had a previous Cesarean Section. Once a Cesarean, always a cesarean.
30% of all cases of Cesarean section birth are due to difficult child birth due to non progressive labor. Another 12% of
Cesarean Sections are performed to deliver a baby in a breech presentation. 9% of all cases, Cesarean Sections are
performed in response to fetal distress. 14% of Cesarean Sections are indicated by other serious maternal factors such as
goiter. By UNICEF (http://www.unicef.org/infobycountry/philippines_statistics.html) The Delivery care (%) 20082012*, Skilled attendant at birth is 62.2 % , Delivery care (%) 2008-2012*, Institutional delivery 44.2% and Delivery
care (%) 2008-2012*, C-section 9.5%
Objectives
General Objective:
After 2 hours of case presentation the students will be able to present a comprehensive study of the cesarean section delivery.
Specific Objective:
Knowledge
To be informed about cesarean delivery.
To plan for needed interventions for the recovery of the patient that underwent cesarean section delivery.
To develop Nursing Care Plan that will meet the needs of patient
To have a subsequent evaluation of the clients conditions and well being
Skills
To obtain sufficient data of the clients history of past and present illness.
To provide a drug study of the medication being administered after delivery.
To do a comprehensive physical examination to a woman who underwent cs delivery.
To analyze the different laboratory examination to the woman who underwent cs delivery.
Attitude
To be able to effectively establish rapport, essential for the cooperation of the client to the health care.
To practice the use of therapeutic use of self for the complete recovery of the patient.
To recognize and understand the clients situation.
To work as a team necessary for this case study.
To practice leadership, a unique trait a student nurse should have.
NURSING ASSESSMENT
PERSONAL HISTORY
Name: Mrs. SM
Address: Marikina City
Age: 28 years old
Sex: Female
Marital Status: Married
Occupation: none
Religion: Methodist
Birthdate: March 8, 1986
Birthplace: Antipolo City
Educational Attainment: College Graduate
Position in the Family: Mother
Health care financing and usual sources of medical care: Philhealth member
Date of Admission: May 19, 2014
Time of Admission: 8:00 am
Admitting Diagnosis: G2P1 (1001) PU 36-37 weeks Age of Gestation
Final Diagnosis: G2P2 (1102)
CHIEF COMPLAINT
Uterine Contraction and Scheduled for Cesarian Section
PAST HISTORY
According to Mrs. SM, during her childhood, she had asthma. She has a
complete immunization which includes diphtheria pertussis, oral polio
vaccine, anti-measles vaccine and BCG.
Young adulthood
Psychosocial
Adulthood
(25 to 65 y/o)
Generativity
VS
Stagnation
Positive Resolution:
Creativity, productivity,
concern for others
Negative Resolution:
Self-indulgence, selfconcern, lack of interests
and commitments
Psychosexual
Cognitive
Moral
Genital
Encourage separation
from parents,
achievement of
independence, and
decision making.
Formal operation
phase:
Growth may be
promoted by major
life events (such as
entry into a new
career or the birth of
a child) or by brain
growth (such as the
development of the
frontal lobe) or,
perhaps, by
interaction of nature
and nurture
Conventional Person is
concerned with maintaining
expectations and rules of
the family, group, nation, or
society. The person values
conformity, loyalty, and
active maintenance of
social order and control.
Spiritual
Individuling reflexive
Constructing ones
own explicit system;
high degree of selfconsciousness.
Description
Remarks
Piagets theory of
cognitive
development is a
manner which
people learn to think
reason and use
language. It involves
a persons
intelligence,
perceptual ability
and ability to
process information.
Lawrence Kohlbergs
theory holds that moral
reasoning is a process that
is principally concerned
with justice and that it
continued throughout the
individuals lifetime.
Learning what ought to be
and ought not to be done.
James W. Fowler,
describes the
development of faith
as a force that gives
meaning to a
persons life. He
believes that the
development of faith
is an interaction
process between the
person and the
environment.
As we observe Mrs. SM is
close with his husband,
children and family. Even
though shes admitted in
the hospital she still thinks
about her family and shes
a jolly person.
Our client is
Methodist. She always
go their church and
she have a high
degree of selfconsciousness.
Positive
Positive
Positive
Positive
Positive
THEORY
THEORIST
DESCRIPTION
Comfort
Theory
Katharine Kolcaba
Environmental
Theory
Florence
Nightingale
Concepts
Person- Patient who is acted on by nurse
Affected by environment
Has reparative powers
Environment- Foundation of theory. Included everything, physical,
psychological, and social
Health- Maintaining well-being by using a persons powers
Maintained by control of environment
Nursing- Provided fresh air, warmth, cleanliness, good diet, quiet to
facilitate persons reparative process
Core, Care,
Cure Model
Lydia Hall
The Vagina
The vagina is a muscular, ridged sheath connecting the external genitals to the uterus, where the embryo
grows into a fetus during pregnancy. In the reproductive process, the vagina functions as a two-way street
accepting the penis and sperm during intercourse and roughly nine months later, serving as the avenue of
birth through which the new baby enters the world.
The Cervix
The vagina ends at the cervix, the lower portion or neck of the uterus. Like the vagina, the cervix has dual
reproductive functions. After intercourse, sperm ejaculated in the vagina pass through the cervix, and then
proceed through the uterus to the fallopian tubes where, if sperm encounters an ovum (egg), conception
occurs. The cervix is lined with mucus, the quality and quantity of which is governed by monthly
fluctuations in the levels of the two principle sex hormones, estrogen and progesterone. When estrogen
levels are low, the mucus tends to be thick and sparse, which makes it difficult for sperm to reach the
fallopian tubes. But when an egg is ready for fertilization and estrogen levels are high the mucus then
becomes thin and slippery, offering a much friendlier environment to sperm as they struggle towards their
goal. (This phenomenon is employed by birth control pills, shots and implants. One of the ways they
prevent conception is to render the cervical mucus thick, sparse, and hostile to sperm.)
Uterus
The uterus or womb is the major female reproductive organ of humans. One end, the cervix,
opens into the vagina; the other is connected on both sides to the fallopian.
The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a
fertilized ovum which becomes implanted into the endometrium, and derives nourishment from
blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an
embryo, develops into a fetus and gestates until childbirth.
Oviducts
The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female
mammals into the uterus. On maturity of an ovum, the follicle and the ovary's wall rupture,
allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus,
pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or
days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the
endometrium when it reaches the uterus, which signals the beginning of pregnancy.
Ovaries
The ovaries are the place inside the female body where ova or eggs are produced. The process
by which the ovum is released is called ovulation. The speed of ovulation is periodic and
impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the
oviduct, where it travelled down the oviduct to the uterus, occasionally being fertilised on its
way by an incoming sperm, leading to pregnancy and the eventual birth of a new human
being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help
the egg cell travel.
PARTS TO BE ASSESSED
TECHNIQUE
NORMAL FINDINGS
ACTUAL FINDINGS
REMARKS
GENERAL APPEARANCE
3.
Clients
overall
Inspection
hygiene & grooming
Clean, neat
NORMAL
Inspection
5. Signs of distress in
posture
or
facial Inspection
expression
6. Obvious signs
health or illness
of
Inspection
No distress noted.
Eye contact
distress noted
and
no
Healthy appearance.
NORMAL
SKIN
1.
Skin
uniformity
color
&
2. Presence of edema
Inspection
No edema.
No edema noted.
NORMAL
3. Skin lesions
Inspection
Freckles,
some
Skin lesion located at
birthmarks, some flat
Deviation from normal
the left hand due to IV
and raised nevi; no
due to formation of
insertion, warts in neck,
abrasions
or
other
scars and warts
and scars in the right leg
lesions.
4. Skin moisture
Palpation
Moisture in skin
and axillae (varies
environmental
temperature
humidity,
temperature
activity.)
5. Skin temperature
Palpation
6. Skin turgor
Palpation
folds
with
Moistened
skin
and especially in the skin NORMAL
body folds.
and
NORMAL
When
pinched,
skin
springs back to previous
Skin returns back to
state.
previous state in less NORMAL
than 1 seconds.
\
NAILS
1.
Fingernails
plate
shape to determine its Inspection
curvature & angle
3. Tissues surroundings
Inspection
nails
Intact epidermis.
Smooth texture.
in
convex
NORMAL
5. Blanch test
capillary refill
of
Palpation
seconds
seconds.)
Hairs
are
distributed.
2. Hair
thinness
Thick/thin hair.
Not present.
No infestations noted
Palpation
Rounded
(normocephalic
and
symmetrical,
with Head is symmetrically
NORMAL
frontal, parietal, and round.
occipital prominences);
smooth skull contour.
thickness
3.
Presence
infections
infestations
&
Palpation
of
or Inspection
evenly
NORMAL
NORMAL
SKULL
1. Size,
symmetry
shape
&
Smooth,
uniform
No mass
consistency; absence of
noted
nodules or masses.
or
nodules
NORMAL
FACE
1. Facial features
Inspection
Symmetric or slightly
asymmetric
facial
features;
palpebral
fissures equal in size;
symmetric nasolabial
folds.
Symmetrical
facial
features;
palpebral
fissures equal in size; NORMAL
nasolabial folds are
symmetrical
2. Symmetry of the
Inspection
facial movements
Symmetrical
movements.
1.
Evenness
of
distribution & direction Inspection
of curl
EYELIDS
Skin
intact,
no
discharge,
no
discoloration. Lids close
symmetrically
approximately
15-20
1.
Surface
involuntary
blinks
per
characteristics
& Inspection and Palpation
minute;
bilateral
ability to blink
blinking.
When
lids
open, no open, no
visible sclera above
corneas, and upper and
lower borders of cornea
are slightly covered.
CONJUNCTIVA
1. Bulbar conjunctivas
color,
texture
& Inspection
presence of lesions
Transparent, capillaries
Transparent; capillaries
evident, no discharge NORMAL
sometimes evident.
was noted.
2.
Palpebral
conjunctivas
color,
Inspection
texture & presence of
lesions
SCLERA
1. Color & clarity
Inspection
Sclera appears
(yellowish
in
skinned clients).
white
dark- Sclera appears white
Inspection
NORMAL
CORNEA
NORMAL
IRIS
1. Shape & color
Inspection
and
NORMAL
PUPILS
1. Color, shape
symmetry of size
&
Inspection
Illuminate
constricts
response)
pupil
Illuminated
(direct
constricts
pupil
NORMAL
Nonillluminated pupil
constricts (consensual Non-illuminated pupil
constricts too. Pupils
response)
dilated when ask to
Pupils constrict when look
on
distant
looking at near object; objects,
constricts NORMAL
pupil
dilates
when when pen was placed
looking at far object; near eyes; when pen
pupils converge when is moved towards the
object
is
moved nose
towards the nose.
No edema noted
NORMAL
NOSE
No discharge and/or
flaring
noted.
Symmetrical on both NORMAL
sides. Also uniform in
color.
2.
Presence
of
redness,
swelling,
growths & discharge or Inspection
nares
using
the
flashlight
Mucosa pink
3. Position
septum
Inspection
of
nasal
5. Tenderness, masses
&
displacement
of Palpation
bone & cartilage
No
tenderness,
no
lesions
noted.
No
NORMAL
displacement of bone &
cartilage.
SINUSES
1.
Presence
tenderness
of
Palpation
Not tender
NORMAL
LIPS
1.
Symmetry
contour
color
texture
Uniform
pink
color
(darker, e.g., bluish
hue, in Mediterranean
groups and dark-skinned
Uniform
pink
color,
clients)
of
smooth,
soft
and
& Inspection and Palpation
NORMAL
Soft, moist, smooth symmetrical. Client is
able to purse lips.
texture
Symmetry of contour
Ability to purse lips
BUCCAL MUCOSA
Uniform
pink
color
(freckled
brown
pigmentation in dark1. Color, moisture,
skinned
clients)Moist,
texture & presence of Inspection and Palpation smooth, soft, glistening,
lesions
and
elastic
texture
(drier oral mucosa in
elderly
due
to
decreased salivation)
Uniform
pink
color.
Moist,
smooth,
NORMAL
glistening and elastic
texture.
TEETH
1. Inspect for color,
number & condition & Inspection
presence of dentures
32 adult teeth
Smooth, white,
tooth enamel
GUMS
Inspection
Moves
freely,
tenderness
no
no No noted nodules or
masses
Positioned in midline of
Midline of soft palate
soft palate.
NORMAL
Pink
and
posterior wall.
NORMAL
smooth Smooth
and
posterior wall
pinkish
3. Gag reflex
Present
Present
2.
Presence
of
tenderness or nodules in Inspection and Palpation
the lymph nodes
Not palpable.
3. Placement
trachea
Inspection
NORMAL
of
the
Inspection
when
NORMAL
BREAST
Engorged Breast with
wider and darker
Symmetrical, no visible
areola, prominent
masses upon inspection.
veins.Tubercle of
Montgomerys enlarged
1.
Symmetry
and
visible mass in Inspection
the breast.
1.
Color, moisture,
Uniformity in color,
texture
and
Uniform in color,
Inspection and Palpation moisture and texture.
presence
of
lesion was noted
No presence of lesion.
lesion
no NORMAL
POSTERIOR THORAX
1. Shape, symmetry &
compare the diameter
of antero posterior Inspection
thorax to transverse
diameter
Anteroposterior
to
transverse
diameter
ratio of 1:2, chest is
symmetric.
2. Spinal alignment
Inspection
3. Breathing excursion
Inspection
5.
Temperature,
Palpation
tenderness, masses
8.
Auscultate
posterior thorax
the
1:2
ratio
of
the
anteroposterior
to
NORMAL
transverse diameter is
symmetric.
Spine
is
vertically
NORMAL
aligned.
No
Adventitious
No adventitious breath
breathing
was NORMAL
sounds.
inspected.
Uniform
skin No mass were palpated
temperature, no masses and
uniform
skin NORMAL
or tenderness.
temperature.
Auscultation
Vesicular
bronchovesicular
breathe sounds.
Bronchovesicular sound
was heard at the upper
and
portion and vesicular
sound was heard at the
lower portion of the
thorax.
NORMAL
Inspection
NORMAL
ANTERIOR THORAX
1. Breathing pattern
Uniform
skin
Uniform
skin
2.
Temperature,
temperature,
neither
Inspection and Palpation temperature, no masses
NORMAL
tenderness, masses
masses nor tenderness
or tenderness.
was palpated.
6.
Auscultate
trachea
the
7.
Auscultate
anterior thorax
the
Auscultation
Bronchial and
breath sounds.
Auscultation
Bronchovesicular
and
Bronchovesicular
and
vesicular breath sounds NORMAL
vesicular breath sounds.
were heard.
CAROTID ARTERIES
1. Pulsation of carotid
Palpation
arteries
2. Auscultation of the
Auscultation
carotid arteries
No sound heard
auscultation.
JUGULAR VEIN
1. Visibility of jugular
Inspection
vein
ABDOMEN
1. Skin integrity
2. Abdominal contour
Inspection
Inspection
3. Enlarge
spleen
liver
or
4. Symmetry of contour
5.
movements
Abdominal
6. Vascular patterns
Palpation
No
evidence
of
No enlargement
enlargement of liver or
observed.
spleen.
Inspection
Symmetric contour.
Inspection
Symmetric
movements
caused by respiration.
Symmetric
movement
Visible peristalsis in very
due
to
respiration. NORMAL
lean
people.
Aortic
Peristalsis not visible.
pulsations in thin persons
at epigastric area.
Inspection
No
visible
pattern.
vascular
Symmetric contour.
was
NORMAL
NORMAL
No
visible
pattern.
vascular NORMAL
7.
Bowel
sounds,
vascular
sound
& Auscultation
peritoneal sounds
8. Percuss
quadrants
abdominal
Percussion
9. Light palpation of
Palpation
abdominal quadrants
Tenderness
may
be
present near xiphoid
process, over cecum,
and over sigmoid colon.
NOT DONE
NOT DONE
MUSCOLOSKELETAL SYSTEM
1. Muscle size compare
the muscles on one side
of the body (arm, thigh, Inspection
calf) to the same muscle
on the other side
2.
Constructures
(shortening)
of
the Inspection
muscles & tendons
No contractures.
No contractures.
NORMAL
3. Muscle fasciculations
& tremors. Presence of
tremors of the hands & Inspection
arms when stretched in
front of the body
No tremors.
No tremors.
NORMAL
4. Muscle tonicity
Inspection
Normally firm.
Firm.
NORMAL
5. Muscle strength
Inspection
1. Normal structure
Inspection
No deformities.
Inspection
No
tenderness
swelling.
Inspection
No swelling.
BONES
or
No deformities
NORMAL
No tenderness.
NORMAL
No swelling.
NORMAL
JOINTS
1. Swelling
2.
Presence
of
tenderness, smoothness
of movement, swelling, Inspection
crepitation & presence
of nodules
RANGE OF MOTION
1. Upper extremities
Inspection
2. Lower extremities
Inspection
Uniform in color, no
Uniform in color, no
deformities, complete Deviation from normal
deformities, complete
fingers in both feet. due to scars.
fingers in both feet.
scars in right leg
General Description
Nursing Responsibility
D5LR
41-42 gtts/min
05/20/14
Prior:
-Check the physicians order in
thrice check
-Explain to the client the
antibiotics and IV that the
patient will encounter
-Monitor the vital signs
-Determine the allergies to
the antibiotics
-Prepare the client for the
surgery
During:
-Check for the physicians
order of doses
-Check for the gtts/min
-Check for the time
management of the medicines
-Monitor the clients response
-Assess the vital signs.
After:
-Monitor the vital signs and
the clients reaction/response
-Check for the physicians
order
-Monitor the ugtts/min
-Time of the medication
-Report and document the
procedure
The
Dextrose 5% in Lactated R
ingers Solution (D5LRS)
is useful for daily
maintenance of body fluids
and nutrition, and for
rehydration.
DRUGS
Generic/Brand
Name
Diclofenac
Voltaren
Date ordered,
Route of
General Action,
Taken/Given, Administratiomn
Classification,
Date
, Doseage,
Mechanism of
change/Discon
Frequency
Action
tinued
50mg PO
-Although its exact
05/19/20
QID
mechanism of
action has not
been fully
elucidated, it
appears to be a
potent inhibitor of
cyclooxygenase,
thereby decreasing
the synthesis of
prostaglandins
Indication
Contraindications
Nursing Responsibilities
bloodglucose.
Methergine
Methylergonovine
Maleate
05/19/14
Tablet PO TID
-Directly stimulates
vascular smoothmuscle
contractions in
uterus and cervix
and decreases
bleeding after
delivery.
-Methylergonovine
maleate(methergin
e) is an ergot
alkaloid that
stimulate smooth
muscle
tissue.Because the
smooth muscle of
the uterus is
especially sensitive
to this drug ,it is
used postpartally
to stimulate the
uterus to contract
in order to
decrease blood loss
by clamping off
uterine blood
vessels and to
promote the
involution
process .In addition
the drug has
vasoconstrictive
effect on all blood
vessels,especially
the larger arteries.
-Prevention and
treatment of postpartum
hemorrhage.
Contraindications
Hypersensitivity to
drug
Hypertension
Toxemia
Pregnancy (except
during third stage of
labor)
Bisacodyl
Dulcolax
05/19/14
Tablet PO TID
-Expands
-Treatment for
intestinal fluid constipation.
volume by
increasing
epithelial
permeability.
-Stimulates
peristalsis by
directing
irritating the
smooth
muscle of the
intestine,
possibly the
colonic
intramural
plexus, alters
water and
electrolyte
secretion
producing
intestinal fluid
accumulation
and laxation.
DIET
TYPE OF
DIET
NPO
(Nothing
Per Orem)
Soft
diet
DATE
ORDERED,DATE
STARTED, DATE
CHANGED, DATE
CONTINUED
May 19,2014
May 20,2014
GENERAL
DESCRIPTION
Nothing by mouth
meaning no food,
medication and
water should be
ingested orally.
PURPOSE
To prevent aspiration
or regurgitation of
gastric contents.
SPECIFIC
FOOD TAKEN
No food,
medication
and water at
all.
For post-operative
cases when patient
can tolerate solid food
but not a full diet
enhances patients
energy for future
activities. Prevent
dehydration and keep
colon contents to a
minimum. Used as a
transition diet
between full liquid
and regular diet.
CLIENTS
RESPONSE
NURSING
RESPONSIBILITIES
Sabi ng doctor
ko wag na muna
daw akong
kumain hanggang
di aq
umuutot,as
verbalized by the
client.
Check for
doctors
order
Monitor vital
signs.
Monitor urine
output
Check for
doctors
order
Monitor vital
signs
Monitor urine
output
ACTIVITY EXERCISE
Type of
Exercise
Date started
Date changed
General Description
ROM(Range
of motion)
Date started
05/19/14
After delivery
ACTIVE ROM
A person
moves each
joints in the
body though
its complete
range of
movement,
maximally
stretching all
muscles groups
within which
plane over the
joint.
Purposes
Clients response
To promote blood
The patient is
circulation.
cooperative and was
To maintain joint
able to perform the
movement.
exercise.
To maintain or
increase flexibility.
Helps to maintain
cardiorespiratory
function.
Nursing responsibilities
Prior
Evaluate clients
response.
Record type of exercise,
degree of joint
abnormalities, and
clients activity
tolerance.
Ambulatio
n
Date
started
05/20/14
Ambulation
is to walk
from place
to place or
the act of
walking.
Early
ambulation
promotes
healing and
prevents
respiratory,
circulatory,
urinary and
gastro intestinal
complication,
also prevent
muscles
weakness.
Prior
sinabi kase
Review clients chart for
sakin ni doc na
physical assessment, findings,
kailangan ko
physicians order, medical
daw maglakad
diagnosis and medical history
pag nakakaya
Determine clients readiness.
ko na as
Explain purpose of ambulation.
verbalized by
During:
After:
SURGICAL MANAGEMENT
Brief Description of the Procedure
A Caesarean Section is surgical procedure in which one or more incisions are made though a mothers
abdomen and uterus to deliver one or more babies, or rarely to remove a dead fetus. A Caesarean Section is
often performed when a vaginal delivery would put the babys mothers life or health at risk. Many are also
performed by request. Both general and regional anaesthesia are acceptable for use during C-section. General
anaesthesia affecting the entire body and accompanied by loss of consciousness. Regional anaesthesia may be
performed as a single shot or with a continuous catheter through which medication is given over a prolonged
period.
Nursing Responsibilities
Prior:
Check the doctors order.
Monitor the vital signs
Encourage conversation to find out the patient's concerns, feelings, and the level of understanding.
Acceptance and understanding instructions surgery
Medicines for fever.
If fever, must be lowered before anaesthesias.
During:
Check for the doctors order
Check for the time management of the medicines
Monitor the clients response
Assess the vital signs
After:
Monitor the vital signs and the clients reaction/response
Check for the doctors order
8 hours after surgery patients are encouraged to have an early ROM and ambulation.
On the second day the patient can stand and sit outside the room.
Report and document the procedure
Subjective:
Masakit yung
tahi ko ,as
verbalized
by
the
client.
Pain scale: 7/10
Objective:
Facial
Grimace
Guarding
behaviour
PR=71
bmp
TEMPERATURE=
37.1 C
RR= 18cpm
BP= 110/70 mmHg
Nursing
Diagnosis
Planning
Intervention
Independent
Encourage use of
relaxation
techniques such
as listening to
music.
Encourage
verbalization of
feelings about
the pain.
Encourage
adequate rest
period.
Instruct
deep
breathing
exercise.
Dependent
Take medicines as
prescribed
Rationale
Increases release
ofendorphins and
enhance
the
therapeutic
effects
ofpain
management
To serve as baseline
data.
To prevent fatigue.
to relieve pain.
Evaluation
GOAL MET
demonstrate ways on
how to manage pain.
GOAL MET
Subjective:
none
Objective:
dressing dry
and intact
Nursing
agnosis
Planning
Intervention
Risk
for Short term goal:
Independent
infection
After 30 minutes
Instruct proper
related
to
of
nursing
handwashing
inadequate
intervention,
the
.
primary
client
and
defense
significant others
secondary to
will be able to
Inspet incision
identify causative
site/dressing.
factors and signs
and symptoms of
infection and report
Note
for
them to the health
fever,chills,
care
provider
diaphoresis,
accordingly.
and
increasing
Long term goal:
abdominal
Within 8 hours,
pain.
the client will be
able to achieve
timely
wound
healing and be free
of
signs
of
infection
and Dependent
inflammation,
Take medicines
purulent drainage
as prescribed
and fever.
Rationale
Evaluation
Subjective:
Hindi
pa
ako
dumudumi
,as
verbalized by the
client.
Objective:
patient has not yet
defecated
normal elimination
pattern has not yet
returned
Nursing
Diagnosis
Planning
Risk
to Short term goal:
constipation
After 30 minutes
related to post
of
nursing
pregnancy
intervention, the
cesarea
client will be
section.
able
to
demonstrate
behaviours
or
plan of lifestyle
change
to
prevent
developing
problems.
Intervention
Independent
Assess client's
normal bowel
pattern abot how
many times a day
she defecates.
Encourage to
increase fluid
intake
Encourage
ambulation within
individual limits.
Rationale
To provide
baseline
information.
To soften stool
and facilitate
passage
through the
colon
To stimulate
contraction
of intestines
and avoid
post
operative
complication.
Evaluation