Nursing

Diagnosis
Impaired
Skin/Tissue
Integrity
related to
mechanical
trauma of
surgical
removal of
skin and
subcutaneou
s tissue
secondary to
Cesarean
section

Backgrou
nd Study
Skin is the
bodys first
line of
defense
against
foreign
materials
that can be
considered
as injuring
agents.
Once the
skin is
disrupted,
this will put
Assessment a person at
Subjective: risk since it
Mayda ak
may
samad kay
become a
gin Cesarean good
ak paganak, medium for
verbalized by bacterial
the client.
growth.
Objective:
Cesarean
Destruction
section,
of skin layers like any
Desruption of other
tissue layers. surgical
(+)Redness
procedures
on the
, includes
incision site.
invasion of
(+)Swelling
the inside
on the
body,
incision site
specifically

INFEREN
CE
Emergenc
y CS

Abdomina
l incision
and
Uterine
incision

Alteration
s of the
Skin

Goals and
Objectives
GOAL:
After 3 days of
nursing
interventions, the
patient will be able
to display timely
healing of skin
lesions/ wounds
without
complication.
OBJECTIVES:
After 8 hours of
nursing
interventions, the
patient will be able
to:
Participate
in
prevention
measures
and
treatment
program
Maintain
physical
well-being.
Ability to
manage
situation.

Interventions

Rationale

Independent
Establish rapport
Perform bedside
care

Inspect skin
daily basis
obseve
changes
unusualities

To gain trust
with the client
To enhance
patients self
esteem and to
provide
comfort to the
patient

on
and
for To determine
and unusual ties
and report it
to physician
for prompt
treatment.
Keep the area
clean, carefully This will assist
dress
wound,
support incison, bodys natural
prevent infection process of

Evaluation
Goal met as
evidenced
by the
patient has
able to
display
timely
healing of
skin lesions/
wounds
without
complication
.

the skin
and
subcutaneo
us area.
(NANDA 9th
edition.pp
461-465)
(MedSurgical
Nursing,
Black and
Hawks 8th
Edition pp
952-954)

repair
Encourage client
to demonstrate
good
skin
hygiene,
e.g.,
wash thoroughly
and
pat
dry
carefully
after
teaching.

DEPENDENT
Medication such
as antibiotics
COLLABORATIV
E
Provide optimum
nutrition such as
increased protein
intake.

Maintaining
clean, dry skin
provides a
barrier to
infection.
Patting skin
dry instead of
rubbing
reduces risk of
dermal
trauma to
fragile skin
To prevent
post operative
wound
complication
To provide a
positive
nitrogen
balance to aid
in healing.
(NANDA 9th
edition pp
461-465)
(Med-Surgical
Nursing, Black
and Hawks 8th

Edition pp
952-954)

Nursing
Diagnosi
s
Acute
pain
related to
abdomina
l incision
secondary
to
surgery.
Subjecti
ve cues:
Masakit
pa an
tinahian
han han
ak tiyan
nan
nakukuria
n ak
pagkiwa
as

Backgroun
d Study

INFERENC
E

Goals and
Objectives

Pain
is
defined as
unpleasant
sensory
and
emotional
experience
arising from
actual
or
potential
tissue
damage or
described
in terms of
such
damage.
(Internation
al
Association
for
the

Emergency
CS

GOAL:
At the end of my
nursing
intervention of 8
hours duty, the
patient will be able
to report pain is
relieved or
controlled.

Abdominal
and uterine
incision
Tissue
trauma

Prostagland
in release+
Uterine
Contraction
+ Loss of
Anesthetic
Effect

OBJECTIVES:
By the of 1hour of
my nursing
intervention, the
client will:

Report pain
intensity
from 4 to 6
will
decrease at

Interventions

Rationale

Independent
Establish
rapport to the
patient

Monitor Vital
signs

Perform
bedside care

To easily gain
cooperation form
the patient
To have baseline
data and for
comparison for
future data
To enhance
patients self
esteem and to
provide comfort to

Evaluatio
n
Goal met
as
evidenced
by the
patient
has able
to
manage
pain
relieve
and
controlled
from 4to 6
to 2-3 on
the pain
rating
scale.

verbalized
by the
patient.
Objectiv
e cues:
Temp:
38.4
C
PR:
88
bpm
RR: 24
cpm
BP:
130/90
mm
Hg
Rated
pain
as 4 to
6 out
of 0 to
10
pain
scale.
Pain
increa
ses
when
moves
vigoro
usly
Incision
site:

Study
Pain);

of
Sensation
of Pain

(Nurses
Pocket
Guide)

Elevated
Vital Signs

2 to 3 from
0 to 10 pain
scale.
Participate
in
demonstrati
ng
techniques
to relieve
pain
Have ability
to manage
situation.

the patient
Observe and
document
location,
severity and
character of
pain.

Promote
bedrest,
allowing patient
to assume
position of
comfort
Control
environment
temperature

By getting the
following
information, we are
asssitting in
differentiating
cause of pain and
providing
information about
disease
progression/resoluti
on, development of
complications and
effective
interventions.
Bedrest in lowfowlers posiiton
reduces
intraabdominal
pressure.

Cool surrounding
aids in minimizing
Employ
non dermal discomfort.
pharmacologic
pain distraction
To prevent
such as:
Music therapy, dependecy on
medication for pain
Imagery,etc
DEPENDENT
Medication
such as

Wound:
dry,
no
discharge
s noted
Dressing
and
plaster
were
clean and
fully
covered
the
incision
site
No foul
odor
noted on
the site.

NSAIDs

Relieves pain
immediately.
(NANDA 9th edition
pp 461-465)