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Assessment Pdx: Pain S>”Nasakit daytoy sugat ko” >Rated pain as 9 from a pain scale of 0-10, 0 as no pain and 10 as worst pain O>Guarding Behavior at the abdomen noted > facial grimaces >Moaning >Hesitant to repositioning. >V/S as follows: BP: 170/150 mmHg RR:17 bpm PR:80 bpm Temp:37.8 oc
Explanation of the Problem The patient is a 42 year old, G3P3 delivered via caesarian section. This procedure includes incision of the abdomen which causes tissue trauma meaning the pain receptors are activated and gives signals to the brain. Therefore presence of pain occurs.
Outcome Criteria STO: After 8 hours of nursing intervention the client will be able to verbalized decrease a pain from 9/10 to 3/10.
Nursing Intervention Dx: note location of surgical procedures Observe non-verbal cues of pain such as holds body, facial expression Assess for referred pain as appropriate Monitor vital signs
Rationale This can influence the amount of post operative pain experienced Serves as effective basis in proper nursing intervention To help determine possibility of underlying condition Vital sign usually altered in acute pain Presence of known/unknown complicating may make the pain more severe
Evaluation STO: After 8 hours of nursing intervention the client will be able to verbalize decrease of pain from 9/10 to 3/10
LTO: After 48 hours of nursing intervention the client will be able to report absence of pain.
Determine possible pathophysiological / psychological causes of pain such as inflammation of surgery. Tx: Perform pain assessment each time pain occurs Provide comfort measures such as changing position Use pain scale rating Provide quiet and clean environment Edx: Encourage adequate rest periods Encourage verbalization of feelings about pain Encourage deep breathing exercises Emphasize importance of wound care Instruct to eat foods rich in proteins
LTO: After 48 hours of nursing intervention the client will be able to report absence of pain
A> Pain related to tissue trauma as manifested by guarding behavior noted at the abdomen and grimacing secondary to low segment caesarian section.
To rule out worsening of development of complications To avoid orthostatic hypotension To determine the severity of the pain To decrease stress
To prevent fatigue To decrease worries For relaxation To avoid colonization of bacteria For fast recovery
Assessment Pdx: Hyperthermia S>”mainit ako” O>V/S as follows: Temp.38.2oC PR- 82 bpm RR- 24 bpm Flushing of face Irritability Lost of appetite Uncomfortable Lost of appetite A>Hyperthermia related to tissue trauma as evidenced by increase temperature.
Explanation of the problem Hyperthermia is caused by the tissue trauma. This is a normal response of the body to fight for a persistent infection that is caused by a certain bacteria which may have entered the body of the patient after the operation, that’s why there is imbalanced body temperature.
Outcome criteria STO: After 2 hours of nursing intervention the client’s temperature will be lower than 38oC.
LTO: After 2 days of nursing intervention the client should have a normal body temperature.
Intervention Dx: Measure and record the V/S of the patient as ordered. Monitor/record all sources of fluid loss such as urine, vomiting, wounds/fistulas, and insensible losses. Note presence/absence of sweating as body attempts to increase heat loss by evaporation, conduction, and diffusion. Tx: Increase fluid intake Provide TSB as needed. Administer antipyretics as ordered. Assist client in bathing and changing into dry clothing when diaphoresis is present and if possible. Administer replacement fluids and electrolytes Maintain bed rest. Provide high-
Rationale Recognizing the pattern of a fever can help determine source. Potentiates fluid and electrolyte losses. Evaporation is decreased by environmental factors, that cause loss of ability to sweat or sweat gland dysfunction Increased metabolic rate and diaphoresis Associated with fever – cause of body fluids To replace the fluids that are lost To lower down the body temperature of the client This will help relieve the symptoms accompanied by fever and lower down the body temperature To support circulating volume and tissue perfusion To reduce metabolic demands/ oxygen consumption.
Evaluation STO: Goal met. After 2 hours of effective nursing intervention the client’s body temperature was lowered down to 37.5oC
LTO: Goal met. After 2 days of effective nursing intervention the client should have a normal body temperature.
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calorie diet, tube feedings or parenteral nutrition.
Edx: Encourages the following: A) Increase fluide intake B) Report any untoward symptom C) Limit activities such as performing ADL alone. D) Increase intake of proteins rich foods, iron and vitamin C.
To meet increased metabolic demands Bathing and clothing changing increase comfort and decrease the possibility of continued shivering caused by water evaporation from the skin. To replace the lost of fluid in the body. To determine any complication and to provide proper intervention. To conserve energy To facilitate wound healing and boost immune system
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Assessment Pdx: Ineffective Tissue Perfusion S>” Wala akong maramdaman pag pinipisil yung paa” O> >(+3) pitting and generalized edema at the lower and upper extremities and face . >400ml/24 hrs of urine. >V/S as follows: Temp. – 37.8oC PR – 78 bpm RR – 18 bpm BP – 170/150 mmHg A>Ineffective tissue Perfusion related to vasoconstriction as manifested by elevated blood pressure
Explanation of the problem Because of the condition of the mother (eclampsia) shearing forces from elevated BP damage the intimal layers of the blood vessels, leading to increase fibrin accumulation and vessel edema. Both the large and small arteries in the body may become atherosclerotic tortuons and weak resulting to narrowing of vessels lumen thereby decreased blood flow to the organ of tissue supplied. As the damaged progresses, the vessels can become occluded or even ruptured causing abrupt cessation of blood flow tot the area. These decrease local auto regulatory controls of blood flow as the vessels are loss able to constrict and dilate in response in response to tissue used.
Outcome Criteria STO: After 8 hours of effective nursing intervention the client will able to decrease blood pressure from 170/150 to 140/110. LTO: After 16 hours of effective nursing intervention the client will able to demonstrate behaviors or lifestyle changes to improve circulation and maintain the normal range of blood pressure. Dx:
Intervention Assess for possible causative factors related to impaired blood flow Monitor and record vital signs for every hour Assess visual disturbances
Rationale Early detection of cause facilitates effective treatment To provide comparisons with current findings Leads to vasospasm and alerts for an indication of probable convulsion To reduce stress, promotes rest and sleep. Exercise prevents venous strains To decrease blood pressure and drug response, half-life, toxic level may by decrease tissue perfusion To decrease anxiety level
Evaluation STO: Goal met. After 8 hours of nursing intervention the client had a blood pressure of 140/110. LTO: Goal partially met because after 16 hours of nursing intervention the client was not able to demonstrate behaviors or lifestyle changes to improve circulation and maintain the normal range of blood pressure she needs further teachings and time to adapt the change.
Tx: Provides quiet environment Do passive range of motion (ROM) exercise
Administer medication as order
Provide information on normal tissue perfusion and possible causes for impairment. Edx: Instruct in blood pressure monitoring at home
To facilitate management of hypertension, which is a major risk factor for
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damage to blood vessel organ function.
Demonstrate or encourage use of relaxation activities, exercises techniques Encourage the client to limit salt and protein intake Suggest limiting intake of coffee and tea.
To decrease tension level and enhances relaxation.
To lessen in contributing to edema. It is contraindicated with the diuretic effect and impact on voiding pattern. Rationale Evaluation STO: Goal met. After 2 hours of effective nursing intervention the client is be able to verbalize and demonstrate correct techniques in cleaning the wound to promote wound healing and to prevent infection LTO: Goal met. After 72 hours of effective nursing intervention the client is not showing any signs and symptoms of infection such as: A) Absence of fever B) Absence of swelling in the incision site C) Absence of pain in the incision site
Assessment Pdx: Risk for Infection A > Risk for Infection related to tissue trauma
Explanation of the Problem The skin is the 1st line of defense against pathogens from entering our body the client has undergone caesarian section during the birth process which made her to have impaired skin therefore making her risk for infection because of the would present that can be a part of microorganisms pathogens which may lead to complications
Outcome Criteria STO: After 2 hours of effective nursing intervention the client will be able to verbalize and demonstrate correct techniques in cleaning the wound to promote wound healing and to prevent infection LTO: After 72 hours of effective nursing intervention the client will not show any signs and symptoms of infection such as: A) Absence of fever B) Absence of swelling in the incision site C) Absence of pain in the incision site Dx:
Assessed risk factors for occurrence of infection Assessed and document skin conditions around the wound Monitored vital signs and recorded Tx: Assisted client in changing wound dressing indicated using proper sterile technique Bedside care done such as changing bed linens Provided safety by raising sire rails Due medication
To prevent the occurrence of risk factors To evaluate when the wound is healing To have a base line and to assess occurrence of infection To reduce risk of contamination of the wound To promote comfort and to reduce spread of micro organisms. To promote safety to decreased risk of fall or injury
To improve healing of the wound.
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given as ordered by physician Edx: Encouraged proper hand hygiene to all caregivers between therapies
To prevent spread of microorganisms. To promote wellness and to prevent occurrence of infection.
Instructed client on how to protect integrity of the skin and how to prevent spread of microorganism.
Encouraged client to eat food rich in protein and iron. Encouraged client not to engage in strenuous activities such as carrying heavy objects Encourage client to maintain sterile technique especially on wound care Encourage early ambulation, DBE, and changing position
Protein and iron can help in promoting healing of wounds by repairing broken tissues.
To prevent bleeding and reopening of the suture.
To reduce risk factors of infection and to prevent spread of microorganisms. To provide fast recovery and to promote comfort. Discontinuation of treatment may result to resistant to the drug. To prevent cell dehydration
Emphasized the necessity of taking antibiotics as ordered. Encourage client to increase fluid intake
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