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Nursing Care Plan for Cesarean Section

Nursing Care Plan for Cesarean Section

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Mabagsak gud man ak tomorrow kan sir leo!!
Mabagsak gud man ak tomorrow kan sir leo!!

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Published by: Jonathan Gabriel Juanico Paquit on Mar 17, 2010
Copyright:Attribution Non-commercial

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12/04/2014

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NursingDiagnosisBackground StudyINFERENCEGoals andObjectivesInterventions Rationale Evaluation
ImpairedSkin/TissueIntegrityrelated tomechanicaltrauma of surgicalremoval of skin andsubcutaneous tissuesecondary toCesareansection
AssessmentSubjective:
“Mayda aksamad kaygin Cesareanak paganak,”verbalized bythe client.
Objective:
Destructionof skin layersDesruption of tissue layers.(+)Rednesson theincision site.(+)Swellingon theincision siteSkin is thebody’s firstline of defenseagainstforeignmaterialsthat can beconsideredas injuringagents.Once theskin isdisrupted,this will puta person atrisk since itmaybecome agoodmedium forbacterialgrowth.Cesareansection,like anyothersurgicalprocedures, includesinvasion of the insidebody,specificallyEmergency CSAbdominal incisionandUterineincisionAlterations of theSkin
GOAL:
After 3 days of nursinginterventions, thepatient will be ableto display timelyhealing of skinlesions/ woundswithoutcomplication.
OBJECTIVES
:After 8 hours of nursinginterventions, thepatient will be ableto:
Participateinpreventionmeasuresandtreatmentprogram
Maintainphysicalwell-being.
Ability tomanagesituation.
Independent
Establish rapportPerform bedsidecareInspect skin ondaily basis andobseve forchanges andunusualitiesKeep the areaclean, carefullydress wound,support incison,prevent infection To gain trustwith the client To enhancepatient’s self esteem and toprovidecomfort to thepatient To determineunusual tiesand report itto physicianfor prompttreatment. This will assistbody’s naturalprocess of Goal met asevidencedby thepatient hasable todisplaytimelyhealing of skin lesions/woundswithoutcomplication. 
 
the skinandsubcutaneous area.(NANDA 9
th
edition.pp461-465)(Med-SurgicalNursing,Black andHawks 8
th
Edition pp952-954)Encourage clientto demonstrategood skinhygiene, e.g.,wash thoroughlyand pat drycarefully afterteaching.
DEPENDENT
Medication suchas antibiotics
COLLABORATIVE
Provide optimumnutrition such asincreased proteinintake.repairMaintainingclean, dry skinprovides abarrier toinfection.Patting skindry instead of rubbingreduces risk of dermaltrauma tofragile skin To preventpost operativewoundcomplication To provide apositivenitrogenbalance to aidin healing.(NANDA 9
th
edition pp461-465)(Med-SurgicalNursing, Blackand Hawks 8
th
 
Edition pp952-954)
NursingDiagnosisBackground StudyINFERENCEGoals andObjectivesInterventions Rationale Evaluation
Acutepainrelated toabdominal incisionsecondarytosurgery.
Subjective cues:
“Masakitpa antinahianhan hanak tiyannannakukurian akpagkiwa”asPain isdefined asunpleasantsensoryandemotionalexperiencearisingfrom actualor potentialtissuedamage ordescribedin terms of suchdamage.(InternationalAssociationfor theEmergencyCSAbdominaland uterineincision TissuetraumaProstaglandin release+UterineContraction+ Loss of AnestheticEffect
GOAL:
At the end of mynursingintervention of 8hours duty, thepatient will be ableto report pain isrelieved orcontrolled.
OBJECTIVES
:By the of 1hour of my nursingintervention, theclient will:
Report painintensityfrom 4 to 6willdecrease at
Independent
Establishrapport to thepatientMonitor VitalsignsPerformbedside care To easily gaincooperation formthe patient To have baselinedata and forcomparison forfuture data To enhancepatient’s self esteem and toprovide comfort toGoal metasevidencedby thepatienthas abletomanagepainrelieveandcontrolledfrom 4to 6to 2-3 onthe painratingscale. 

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