You are on page 1of 37

X.

GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Pattern Actual Findings Interpretation


Patient AB regularly visits Gat Andres The patient has the eagerness to
Bonifacio Memorial Medical Center maintain her health due to the fear of
(GABMMC) to have her prenatal check-up, spending so much just to suffice their
but she rarely takes her prenatal vitamins medical needs. Because of financial
due to financial constraints. “Ipapambili ko constraint, she is not able to give more
na lang ng pagkain namin kaysa sa importance to her health. Fortunately, she
Health Perception/ Health Management
gamot,” added by the patient. was still able to go to the nearest hospital
During admission, the patient believes for her prenatal check-up.
that she’s having high blood pressure
because of the overdosage of ferrous
sulfate. Because of this, she decided to
stop taking the said medication.
Patient AB usually prepares any food The patient’s nutritional status is poor
she can buy from their money, but still before and during her admission. Because
eats her meal thrice a day with no snack in of a diet low in essential nutrients, her
between. She drinks a cup of coffee with CBC results showed decreasing
her dinner. She also claimed not having hemoglobin. The patient wanted to have a
Nutritional/Metabolic
any allergies or religious restrictions in healthy lifestyle, but because of their low
foods. socioeconomic level her health is limited to
During admission, the patient’s daily what their money can buy.
meal is limited to what she can only afford.
But she’s not a picky eater, and that she
eats any food available.
Patient AB voids 5-7 times a day The patient’s elimination is affected
before admission with her urine yellow in when she was admitted due to the
color and no burning sensation or pain felt discomforts brought about by the assistive
during urination. She usually moves her equipment which is supposed to be
bowel every morning with brown and helping the patient.
Elimination
formed stools.
But during admission, she verbalized
difficulty in voiding (4-5 times a day; brown
in color) due to the pain brought by the
Foley catheter attached in her.
The patient usually ambulates within Due to her surgical incision,
the house, doing the household chores, decreased hemoglobin, and an inserted
walking in their neighborhood early in the Foley catheter, the patient wasn’t able to
morning as her exercise, and sends her endure or complete desired daily activities
kids to school which is walking distance leading to activity intolerance. Hence, the
from their home without any complaint of patient’s activity and exercise pattern is
Activity-Exercise weakness. affected.
But recently upon admission, she
feels tired easily that she cannot walk for
15 minutes continuously without complaint
of weakness. She also added that she has
been less productive lately and she cannot
move freely because of the Foley catheter
attached to her.

Patient AB can sleep for 6 hours every Based from these findings, we may
night. Her earliest time in going to sleep is conclude that the patient feels restless
at 9:30 pm. Latest time in waking up is at even after sleep. Because of this
4:00 am. She sometimes takes a nap at discomfort, her sleep-rest pattern is also
noon for about 1-2 hours. She has no affected.
Sleep-Rest
difficulties in going to sleep and doesn’t
use any medication to promote sleep.
During admission, the patient
verbalizes difficulty of going to sleep
because she feels warm at night.
Patient AB has no sensory deficits. The patient used to have normal
But during admission, her functions are cognitive-perceptual pattern as her
diminished due to complaints of pain in the pregnancy progresses, but as she was
Cognitive-Perceptual incision site and weakness. Despite these admitted with an underlying condition, the
complaints, she is still oriented in people, pattern seems to be affected.
time, and place, and responds to stimuli
verbally and physically.
Patient AB described herself as a The patient realized the importance
“happy go lucky” person when she was a of utilizing health care resources to help
teenager. She feels contented with her her in managing her condition. She’s also
Self-Perception and Self-Concept
usual lifestyle as long as she doesn’t feel aware of how she looks, but firmly ignores
any discomforts, so as not to seek medical it. Therefore, there is a change to the level
assistance of patient’s self-perception and self-
Recently, she believed that admission concept due to her present condition.
will be helpful to assist her in her needs.
She also verbalized that “alam kong
malosyang ako,” but she firmly continued,
saying “pero ‘di naman big deal, malakas
kasi loob ko.”
Patient AB is a mother of five children, The patient’s role-relationship pattern
and lives with them and her husband. She is also affected by her condition. She was
loves her family so much. She is well- not able to do her role as a mother of her
supported and loved also by her family other kids, except her newly born baby
with close relationship. As a mother, she whom she puts more of her attention.
wakes up 4 am in the morning to prepare However, the patient still exerts effort to at
and send two of her kids to school. least have contact with her children. Her
Role-Relationship
However, during admission she role as a wife is also affected, she
cannot see her children anymore. Her role verbalized that her husband understood
as a mother to her other kids is temporarily her situation and that he’s willing to be a
passed to her husband. But efforts to have “mother” of their kids for now.
contact with them is evident, and so she
was able to describe herself as “ulirang
ina.”
Patient AB revealed being sexually Because the patient already
active and sexually satisfied with her experienced a lot of pain in labor and
Sexuality-Reproductive
sexual relationship without using any delivery, and she’s already satisfied of
contraceptives. Her menarche happened having 6 children, the patient made a
when she was 11 years old, had her first decision of ending her chance of being
sexual intercourse when she was 14 years pregnant again. She thinks that it’s a good
old and currently had six pregnancies. decision for her own benefit and for the
During admission, the patient sake of conserving their family’s income to
verbalized that she’s already contented of suffice their needs.
the pregnancies she had, and doesn’t
want to feel the pain anymore so she
decided to have her fallopian tubes
ligated.
Patient AB copes up with stress by The patient is aware of the different
taking a nap, or by talking about it with her ways in managing stress. Her strong bond
husband and her mother, and find ways to with her husband and mother seems to be
resolve it together. She had two abortions helpful in handling problems including her
already, and had a sister who committed present condition. Therefore, the patient
suicide, but she is able to accept the loss has a coping pattern that is effective in
of her loved ones because of the support stress tolerance. And due to an available
Coping-Stress Tolerance she gets from her significant others. Her support system, the patient was able to
family also understood and supported her control and manage situations knowing
in her decision of undergoing a bilateral that someone is there to support her.
tubal ligation for the reason that “ayoko na
sundan pa,” as stated by the patient.
During admission, her mother was
seen on bedside. However, her husband
was not there to support her because no
one will be there to see their kids, and as
the breadwinner of the family, he needs to
work especially there’s another member of
their family. But the patient still has a
positive outlook, saying that
“nagpapakatatag ako para sa pamilya ko.”
Patient AB is an active member of the Because of her strong spiritual
Catholic Church. She has strong faith in stability and proper stress management as
God, and puts importance to her family. said earlier, she will have a guide in
There are no restrictions or conflicts making her choices or decisions in life.
related to health brought by her religion. Therefore, there is an assurance that the
During admission, the patient still patient can face any problems including
Value-Belief prays every night before going to sleep, her present condition.
and believes that nothing bad will happen
to her and her baby, and that sooner both
of them will go back to their home and her
baby will be able to meet his father and
siblings. Her hospitalization does not
interfere with her religious practice.
XI. REVIEW OF SYSTEMS

System of the Body Actual Findings


“Madalas akong manghina,” as verbalized by the patient.

General Overall Health State Patient AB is awake and alert, but with signs of acute distress as
she said.
“Ang sakit ng tahi ko tapos ang hapdi ng utong ko,” as

Integumentary System verbalized by the patient. Patient AB reported feelings of pain on


the surgical incision over her abdomen with a rate of 8 out of 10.
“Hindi naman ako hirap huminga,” as verbalized by the
Respiratory System patient. Patient AB has no problems with her respiratory system.
“Ang baba ng dugo ko,” as verbalized by the patient. Patient
AB has decreased hemoglobin level as shown in her CBC
Circulatory System
results, so she has undergone two blood transfusions after
delivery.
“Madalas akong namumutla,” as verbalized by the patient.
Patient AB reported paleness of her lips and mucous membrane
Peripheral Vascular System She also verbalizes numbness on the surrounding area of her
incision. Other than that, she has no other problems with her
peripheral vascular system.
“Di naman ako mapili sa pagkain,” as verbalized by the
patient. Patient AB confirmed that she has no loss of appetite,
Gastrointestinal System
food intolerance, or any other problems with her gastrointestinal
system.

Urinary System “Nahihirapan ako umihi kasi naka-catheter ako tapos


napansin ko nag-iba kulay ng ihi ko,” as verbalized by the patient.
Patient AB complained difficulty of voiding from 5-7 times a day
to 4-5 times a day. She also noticed the change in the color of
her urine from the usual light yellow to brown. However, upon
interview, she denies history of urinary disease or history of
surgery in the urinary system.
“Wala naman akong problema sa pwerta ko,” as verbalized
by the patient. Patient AB hasn’t reported any abnormal vaginal
Female Genital System
discharge, has no complaints in her genitals, and practices
proper perineal hygiene.
“Nanghihina ako, hirap akong kumilos kasi ang sakit ng tahi
ko tapos may catheter pa ko,” as verbalized by the patient.
Patient AB experienced muscle weakness due to low Hgb level,
Musculoskeletal System
and so, has limited range of motion. The patient also has a newly
incised wound and a Foley catheter attached limiting her
movements.
“Minsan nahihilo ako dahil siguro sa baba ng dugo ko,” as
verbalized by the patient. Patient AB sometimes experienced
Neurologic System
lightheadedness due to lack of Hgb level upon CBC, but has no
history of fainting or blackouts.
“Wala namang problema,” as verbalized by the patient.
Endocrine System Patient AB has no problem with her endocrine system. She
doesn’t have history of diabetes mellitus or even thyroid disease.
XII. PHYSICAL ASSESSMENT

Last February 24, 2017 and March 2, 2017, we conducted a physical assessment on our patient. The first thing we did was to
build a good nurse-patient interaction. We explained what we will do and why is it necessary and how she can cooperate. The patient
agreed to be physically examined.

Part of the Body Normal Findings Actual Findings Deviation from Normal

Skin: The client’s skin is Skin: The client’s skin is pallor Skin: The client’s skin is pale
uniform in color, unblemished and no presence of any foul and has a cold and dry skin.
and no presence of any foul odor. She has a cold and dry
odor, has a good skin turgor, skin.
and skin’s temperature is
within normal limit.
Hair: The hair of the client is Hair: The hair of the client is Hair: There is no deviation
thick, silky hair is evenly thick, silky hair and is evenly from normal findings.
distributed and has a variable distributed and has a variable
Integumentary
amount of body hair. There are amount of body hair. There are
also no signs of infection and also no signs of infection and
infestation observed. infestation observed.
Nails: The client has a light Nails: The client has a long Nails: The client has a long
brown nails and has the shape and dirty nails and has the and dirty nails.
of convex curve. It is smooth shape of convex curve. It is
and is intact with the epidermis. smooth and is intact with the
When nails pressed between epidermis. When nails pressed
the fingers (Blanch Test), the between the fingers (Blanch
nails return to usual color in Test), the nails return to usual
less than 4 seconds color in 3 seconds.
Head: The head of the client is Head: The head of the client There is no deviation from
rounded; normocephalic and is rounded; normocephalic normal findings.
symmetrical. and symmetrical.
Skull: There are no nodules or Skull: There are no nodules
masses and depressions when or masses and depressions
Head palpated. when palpated.
Face: The face of the client Face: The face of the client
appeared smooth and has appeared smooth and has
uniform consistency and with uniform consistency and with
no presence of nodules or no presence of nodules or
masses. masses.
Eyebrows: Hair is evenly Eyebrows: Hair is evenly The palpebral conjunctiva
distributed. The client’s distributed. The client’s appeared pale.
eyebrows are symmetrically eyebrows are symmetrically
aligned and showed equal aligned and showed equal
movement when asked to movement when asked to
Eyes and Vision raise and lower eyebrows. raise and lower eyebrows.
Eyelashes: Eyelashes Eyelashes: Eyelashes
appeared to be equally appeared to be equally
distributed and curled slightly distributed and curled slightly
outward. outward.
Eyelids: There were no Eyelids: There were no
presence of discharges, no presence of discharges, no
discoloration and lids close discoloration and lids close
symmetrically with involuntary symmetrically with involuntary
blinks approximately 15-20 blinks approximately 15-20
times per minute. times per minute.
Eyes Eyes
o The Bulbar conjunctiva o Transparent bulbar
appeared transparent with conjunctiva with few
few capillaries evident. capillaries noted.
o The sclera appeared white. o The sclera appeared white.
o The palpebral conjunctiva o The palpebral conjunctiva
appeared shiny, smooth appeared pale.
and pink.
o There is no edema or o There is no edema or
tearing of the lacrimal gland. tearing of the lacrimal
gland.
o Cornea is transparent, o Cornea is transparent,
smooth and shiny and the smooth and shiny and the
details of the iris are visible. details of the iris are visible.
The client blinks when the The client blinks when the
cornea was touched. cornea was touched.
o The pupils of the eyes are o The pupils of the eyes are
black and equal in size. The black and equal in size. The
iris is flat and round. iris is flat and round.
PERRLA (pupils equally PERRLA (pupils equally
round respond to light round respond to light
accommodation), accommodation),
illuminated and non- illuminated and non-
illuminated pupils constricts. illuminated pupils
Pupils constrict when constricts. Pupils constrict
looking at near object and when looking at near object
dilate at far object. Pupils and dilate at far object.
converge when object is Pupils converge when
moved towards the nose. object is moved towards the
nose.
o When assessing the o When assessing the
peripheral visual field, the peripheral visual field, the
client can see objects in the client can see objects in the
periphery when looking periphery when looking
straight ahead. straight ahead.
o When testing for the o When testing for the
Extraocular Muscle, both Extraocular Muscle, both
eyes of the client eyes of the client
coordinately moved in coordinately moved in
unison with parallel unison with parallel
alignment. alignment.
o The client was able to read o The client was able to read
the newsprint held at a the newsprint held at a
distance of 14 inches. distance of 14 inches.
The auricles are symmetrical The auricles are symmetrical There is no deviation from
and has the same color with and has the same color with normal findings.
his facial skin. The auricles his facial skin. The auricles
are aligned with the outer are aligned with the outer
canthus of eye. When canthus of eye. When
palpating for the texture, the palpating for the texture, the
Ears and Hearing
auricles are mobile, firm and auricles are mobile, firm and
not tender. The pinna recoils not tender. The pinna recoils
when folded. During the when folded. During the
assessment of Watch tick test, assessment of Watch tick test,
the client was able to hear the client was able to hear
ticking in both ears. ticking in both ears.
Nose: The nose appeared Nose: The nose appeared The patient has nasal flaring,
symmetric, straight and symmetric, straight and pale and dry lips; pale gums
uniform in color. There was no uniform in color. There was no and buccal mucosa.
presence of discharge or nasal presence of discharge, but
flaring. When lightly palpated, there is a presence of nasal
Nose and Sinus there were no tenderness and flaring. When lightly palpated,
lesions. there were no tenderness and
lesions.
Mouth: Mouth:
o The lips of the client are o The lips of the client are
uniformly pink; moist, pale in color; dry and
symmetric and have a symmetric. The client was
smooth texture. The client able to purse his lips when
was able to purse his lips asked to whistle.
when asked to whistle.
o Teeth and Gums: There o Teeth and Gums: There
are no discoloration of the are no discoloration of the
enamels, no retraction of enamels, no retraction of
gums, pinkish in color of gums but has paleness in
gums color of gums. She is
o The buccal mucosa of the wearing retainers.
client appeared as uniformly o The buccal mucosa of the
pink; moist, soft, glistening client appeared as pale and
and with elastic texture. dry.
o The tongue of the client is o The tongue of the client is
centrally positioned. It is centrally positioned. It is
pink in color, moist and pink in color, moist and
slightly rough. There is a slightly rough. There is a
presence of thin whitish presence of thin whitish
coating. coating.
o The smooth palates are o The smooth palates are
light pink and smooth while smooth while the hard
the hard palate has a more palate has a more irregular
irregular texture. texture.
o The uvula of the client is o The uvula of the client is
positioned in the midline of positioned in the midline of
the soft palate. the soft palate
o The neck muscles are equal o The neck muscles are There is no deviation from
in size. The client showed equal in size. The client normal findings.
coordinated, smooth head showed coordinated,
movement with no smooth head movement
discomfort. with no discomfort.
o The lymph nodes of the o The lymph nodes of the
client are not palpable. client are not palpable.
Neck o The trachea is placed in the o The trachea is placed in the
midline of the neck. midline of the neck.
o The thyroid gland is not o The thyroid gland is not
visible on inspection and the visible on inspection and
glands ascend during the glands ascend during
swallowing but are not swallowing but are not
visible. visible

o Lungs/Chest: The chest o Lungs/Chest: The chest There is an inch-sized scar


wall is intact with no wall is intact with no superficial to the sternum due
tenderness and masses. tenderness and masses. to a past accident 8 years ago.
Lungs and Heart There’s a full and symmetric There’s a full and
expansion and the thumbs symmetric expansion and
separate 2-3 cm during the thumbs separate 2-3
deep inspiration when cm during deep inspiration
assessing for the respiratory when assessing for the
excursion. The client respiratory excursion.
manifested quiet, rhythmic There is also an inch-sized
and effortless respirations. scar due to a past accident.
o The spine is vertically o The spine is vertically
aligned. The right and left aligned. The right and left
shoulders and hips are of shoulders and hips are of
the same height. the same height.
o Heart: There were no o Heart: There were no
visible pulsations on the visible pulsations on the
aortic and pulmonic areas. aortic and pulmonic areas.
There is no presence of There is no presence of
heaves or lifts. heaves or lifts.
The abdomen of the client has The abdomen of the client has There is a 15 centimeter
an unblemished skin and is a 15 centimeter classical classical incision in the midline
uniform in color. The abdomen incision in the midline of the of her abdomen. Normal signs
has a symmetric contour. abdomen and has striae of pregnancy like striae
There were symmetric gravidarum 3-5 cm long on her gravidarum 3-5 inch in length
Abdomen
movements caused associated lower abdomen. There were were also noted
with client’s respiration. The symmetric movements caused
jugular veins are not visible. associated with client’s
respiration. The jugular veins
are not visible.
Extremities o The extremities are o The extremities are There is a decreased range of
symmetrical in size and symmetrical in size and motion with weakness in both
length. length. upper and lower extremities.
o Muscles: The muscles are o Muscles: The muscles are
not palpable with the not palpable with the
absence of tremors. They absence of tremors. They
are normally firm and have decreased range of
showed smooth, motion with weakness in
coordinated movements. both upper and lower
extremities.
o Bones: There were no o Bones: There were no
presence of bone presence of bone
deformities, tenderness and deformities, tenderness and
swelling. swelling.
o Joints: There were no o Joints: There were no
swelling, tenderness and swelling, tenderness and
joints move smoothly. joints move smoothly.

POSTPARTUM ASSESSMENT

Breast – The patient’s has cracked nipples on her left breast. Both of her breasts are firm with no engorgement upon palpation.

Uterus – The uterus of the patient is not anymore palpated, because she doesn’t undergone a vaginal delivery, but rather, a
cesarean delivery with surgical incision that is dry and has no infestations or further complications.

Bowel – The patient moves her bowel every morning with formed, brown stool.
Bladder – The patient has a Foley catheter draining to urine bag with brown urine output, and voids 4-5 times a day

Lochia – The patient has no lochia since she did not deliver her baby vaginally.

Episiotomy – The patient also has not undergone episiotomy.

Skin – The patient’s skin is pale, cold and dry with poor capillary refill.

Homan’s sign – The patient has a negative Homan’s sign.

Emotions – The patient is conscious, stable, and eager to see her baby.
C. DRUG ANALYSIS

Drug Study #1

Name of the Dosage and Mode of Nursing


Classification Indication Side Effects
Drug Frequency Action Considerations
Generic Therapeutic: 500 mg BID Pharyngitis, tonsillitis, Inhibits cell Body as a - Determine history
Name: Antibiotic; x 7 days p.o. infections of the urinary wall Whole: of hypersensitivity
Cefuroxime Pharmacologic: Available and lower respiratory synthesis Superinfections, reactions to
Brand Second- Dosage: tracts, and skin and skin- promoting positive cephalosporins,
Name: generation 750 mg structure infections osmotic Coombs'test. penicillins, and
Zinacef cephalosporin IV/IM q8h caused by Streptococcus instability; GI: history of allergies,
pneumoniae and S. usually Diarrhea, particularly to drugs,
pyogenes, Haemophillus bactericidal. nausea, before therapy is
influenzae,Staphylococcus antibiotic- initiated.
aureus, and Escherichia associated - Perform culture
coli. colitis. and sensitivity tests
Skin: before initiation of
Rash, pruritus, therapy and
urticaria. periodically during
Urogenital: therapy if indicated.
Increased Therapy may be
serum ketone instituted
and pending test results.
BUN, decreased Monitor periodically
creatinine BUN and
clearance creatinine clearance.
- Report onset of
loose stools or
diarrhea.
- Monitor for
manifestations of
hypersensitivity
Discontinue drug
and report their
appearance
promptly.
- Monitor
I&O rates and
pattern. Report any
significant changes.
- Instruct patient not
to breast feed while
taking this drug.
Drug Study #2

Name of the Dosage and Nursing


Classification Indication Mode of Action Side Effects
Drug Frequency Considerations
Generic Name: Therapeutic: 500 mg TID p.o. Short- Anthranilic acid CNS: Drowsiness, - Assess if
Mefenamic Acid Analgesic, Available term relief of mild derivative. Like insomnia, patient develops
Brand Name: Antipyretic Dosage: to moderate pain ibuprofen dizziness, severe diarrhea
Ponstel Pharmacologic 250 mg tab q6h inhibits nervousness, and vomiting for
: NSAID prn prostaglandin confusion, dehydration and
synthesis and headache. electrolyte
affects platelet GI: Severe imbalance.
function. No diarrhea, - With long-term
evidence that it ulceration, and therapy (not
is superior to bleeding; nausea, recommended),
aspirin. vomiting, obtain periodic
abdominal cramps, complete blood
flatus, constipation, counts, Hct and
hepatic toxicity. Hgb, and kidney
Hematologic: function tests.
Prolonged - Discontinue
prothrombin time, drug promptly if
severe diarrhea, dark
autoimmune stools,
hemolytic anemia hematemesis,
(long-term use), ecchymoses,
leukopenia, epistaxis, or
eosinophilia, rash occur and
agranulocytosis, do not use
thrombocytopenic again. Contact
purpura, physician.
megaloblastic - Notify
anemia, physician if
pancytopenia, persistent GI
bone marrow discomfort, sore
hypoplasia. throat, fever, or
Urogenital: malaise occur.
Nephrotoxicity, - Instruct patient
dysuria, not to drive or
albuminuria, engage in
hematuria, potentially
elevation of BUN. hazardous
Skin: Urticaria, activities until
rash, facial edema. response to drug
Special Senses: is known. It may
Eye irritation, loss cause dizziness
of color vision and drowsiness.
(reversible), blurred - Monitor blood
vision, ear pain. glucose for loss
Body as a Whole: of glycemic
Perspiration. control if
CV: Palpitation. diabetic.
Respiratory: - Instruct patient
Dyspnea; acute not to breast
exacerbation of feed while taking
asthma; this drug without
bronchoconstriction consulting
(in patients physician.
sensitive to
aspirin).
Drug Study #3

Name of the Dosage and Nursing


Classification Indication Mode of Action Side Effects
Drug Frequency Considerations
Generic Name: Therapeutic: 325 mg, 1 tab Iron-deficiency Elevates the GI: - Advise patient
Ferrous sulfate Essential BID. p.o. anemia serum iron Constipation, to take medicine
Brand Name: Minerals Available concentration gastric irritation, as prescribed.
Feosol Pharmacologic: Dosage: which then helps nausea and - Caution patient
Oral iron 160 mg to form Hgb or vomiting, to make position
supplement sustained trapped in the abdominal changes slowly
release tablets, reticuloendothelial cramps, to minimize
capsules; 167 cells for storage anorexia, orthostatic
mg tablets; 200 and eventual diarrhea and hypotension.
mg tablets; 525 conversion to a dark-colored - Instruct patient
mg timed usable form of stools. These to avoid
release tablets; iron. effects may be concurrent use
150 mg minimized by of alcohol or
capsules; 190 administering OTC medicine
mg capsules; preparations as without
250 mg a coated tablet. consulting the
capsules; 90 Soluble iron physician.
mg/5 mL syrup; preparations - Advise patient
220 mg/5 mL may stain the to consult
elixir; 75 mg/0.6 teeth. physician if
mL drops irregular
heartbeat,
dyspnea,
swelling of
hands and feet
and hypotension
occurs.
- Inform patient
that angina
attacks may
occur 30 min.
after
administration
due reflex
tachycardia.
- Encourage
patient to comply
with additional
intervention for
hypertension like
proper diet,
regular exercise,
lifestyle changes
and stress
management.
XVI. NURSING CARE PLAN

Nursing Care Plan #1

Nursing Nursing
Assessment Inference Goal/ Objective Rationale Evaluation
Diagnosis Interventions
Subjective: Impaired skin Skin integrity The patient will Independent: Goal was
“Ang sakit ng integrity related may be display timely - Establish - This would partially met as
tahi ko sa tiyan,” to presence of compromised healing of therapeutic allow both evidenced by a
as verbalized by surgical incision due to several surgical wound nurse-client patient and timely healing
the patient. after cesarean factors including without relationship. nurse to be able process of
delivery as mechanical complication to trust and be surgical wound
Objective: manifested by factors such as after 4-6 weeks comfortable with without any
- classical verbalization of trauma brought of nursing one another. complications
incision is 15 cm pain on the by a surgery. interventions. - Monitor vital - Increased body observed.
in length noted affected area Since cesarean signs every 4 temperature may
in midline of the delivery requires hours. indicate a
abdomen incision, scarring developing
- dry and intact and destruction infection from
surgical incision of skin layers the wound.
- pain scale of occurs. This - Assess surgical - To monitor
8/10 on affected results to wound for length, progress of
and surrounding impaired skin width, depth of wound healing.
area integrity, as injury,
- post surgical experienced by temperature or
day (02/24/17; 1 the patient presence of any
day after involved. discharges on a
delivery) daily basis. (Note
- numbness Reference: for odors emitted
upon palpation - NANDA 13thed from the wound).
is noted (Doenges et al., - Keep the area - To assist
- guarding 2013) clean/dry, body’s natural
attitude in carefully dress process of
incision site (at wounds, support repair.
first she doesn’t incision, prevent
want to allow to infection, and
touch and see stimulate
her incision site) circulation to
- V/S are as surrounding
follows: areas.
BP: 120/90 - Emphasize - To reduce
mmHg importance of pressure or
RR: 19cpm proper fit of enhance
PR: 82bpm clothing/dressing. circulation to
T: 36.9 C compromised
tissues.
- Encourage - To provide
optimum nutrition positive nitrogen
including balance to aid in
vitamins (e.g. A, skin/tissue
C, D & E) and healing and to
increase protein maintain general
intake. good health.
- Encourage - To promote
diversional fast healing
activities. process.
Dependent:
- Administer - To provide
medications pharmacological
ordered by the management of
physician. the condition.
Collaborative:
- Obtain -To determine
specimen from appropriate
draining wound therapy.
when appropriate
for C&S or
Gram’s stain.
- Consult with - To assist with
wound specialist developing plan
as indicated. of care if wound
becomes
potentially
critical.
Nursing Care Plan #2

Nursing Goal/ Nursing


Assessment Inference Rationale Evaluation
Diagnosis Objective Interventions
Subjective: Ineffective Without After 3 days of Independent: Goal was met
“Madalas akong tissue perfusion adequate iron, nursing - Establish - This would as evidenced by
manghina at related to the body can’t intervention, the therapeutic nurse- allow both increased
mamutla decreased produce enough patient will be client relationship. patient and perfusion
matapos akong hemoglobin hemoglobin for able to nurse to be able
manganak,” as concentration in red blood cells. demonstrate to trust and be
verbalized by the blood as Decrease increased comfortable with
the patient. manifested by hemoglobin perfusion one another.
pale skin. reduces uptake - Monitor vital signs -To gather
of oxygen at every 4 hrs. accurate data of
Objective: alveolar patient.
- capillary refill capillary - Provide - Knowledge of
(4-5 seconds) membrane and knowledge on causative factors
- pallor may result with normal tissue provides a
- cool and dry insufficient perfusion and rationale for
skin oxygen delivery possible causes of proper
- dizziness to the tissues impairment. treatment.
- weakness in leading to - Elevate head of - To promote
both upper and ineffective bed about 10 good circulation.
lower tissue degrees and
extremities. perfussion maintain head and
- decreased neck into midline or
range of motion. neutral position.
- Hemoglobin - Encourage patient - To decrease
values: Reference: to be at ease. tension level.
 4 months - NANDA 13thed - Encourage - It contains
before CS (Doenges et al., increase nutritional good sources of
delivery 2013) food intake mostly heme iron that
(113gm/l) rich in iron such as can possibly
 18 days dark green leafy increase
before CS vegetables, beans, production of
delivery liver and more. hemoglobin.
(111gm/l) - Encourage - Increase fluid
 after delivery increase fluid intake intake prevents
and blood circulatory
transfusion shocks and it
(94gm/l) maintains good
- V/S are as circulation.
follows: DEPENDENT:
BP: 120/90 - Administer IV - Sufficient fluid
mmHg fluids as ordered by intake maintains
RR: 19cpm physician. adequate filling
PR: 82bpm pressures and
T: 36.9 C optimizes
cardiac output
needed for
tissue perfusion.
- Administer - Medications
medications prescribed can
prescribed. facilitate
perfusion.
- Administer blood - To renew lost
transfusion as red blood cells
ordered. and possibility of
stabilizing
hemoglobin
levels.
Collaborative:
- Refer for CBC - To be able to
monitoring monitor and
especially maintain normal
hemoglobin level. values of
hemoglobin
which is 120-180
gm/l.
Nursing Care Plan #3

Nursing Goal/ Nursing


Assessment Inference Rationale Evaluation
Diagnosis Objective Interventions
Subjective: Activity The common After 2 days of Independent: Goal was met.
“Hirap ako intolerance etiology of nursing - Establish - This would The patient is
makagalaw dahil related to activity interventions therapeutic nurse- allow both able to walk
sa tahi ko, pati surgical incision intolerance is the patient will client relationship. patient and without any
na rin sa aking as manifested related to be able to walk nurse to be able discomfort and
catheter,” as by guarding generalized continuously to trust and be weakness
verbalized by attitude weakness and without comfortable with
the patient. debilitation from verbalization of one another.
acute or chronic weakness - Encourage the - To be able to
Objective: pain or illnesses patient to verbalize render proper
- weakness due to post her feelings. treatment and
- loss of surgical interventions
productivity incision. The accurately.
- pallor patient is - Monitor vital signs - To allow her
- post surgical incapacitated every 4 hrs. urine to change
day (02/24/17; 1 and has poor from brown to
day after circulation yellow and be
delivery) which causes able to urinate
- classical poor exercise independently
incision is 15 cm tolerance. - Encourage - To be able to
in length noted increase intake of recover as soon
in midline of the Reference: fluids. as possible and
th
abdomen. - NANDA 13 ed also in need of
- presence of (Doenges et al., conserving
Foley catheter 2013) energy.
draining to urine - Instruct patient to - To reduce
bag with brown increase exercise fatigue.
urine output. or activity levels
- guarding gradually.
attitude in - Encourage rest - To enhance
incision site (at periods between ability to
first, she doesn’t activities such as participate in
want to allow to stopping to rest for activities.
touch and see 3 minutes during a
her incision site) 10-minute walk.
- pain scale of - Promote comfort - To be able to
8/10 measures and ambulate safely
- V/S are as provide for relief of and without
follows: pain such as causing injuries.
BP: 120/90 limiting visitors,
mmHg periods of
RR: 19cpm uninterrupted rests,
PR: 82bpm necessities keep in
T: 36.9 C reach and
minimizing noisy
environment.
- Assist in range of - To support,
motion exercises. heal and protect
incision sites.
- Encourage the - To help
use of abdominal transport oxygen
binder. effectively.
Dependent:
- Administer - To develop and
supplemental individually have
oxygen or any appropriate
medications therapeutic
ordered by the regimens.
physician.
Collaborative:
- Refer to physical - For proper
therapists or treatment.
exercise
physiologist.
Nursing Care Plan #4

Nursing Goal/ Nursing


Assessment Inference Rationale Evaluation
Diagnosis Objective Interventions
Subjective: Ineffective After After 2 hours of Independent: Goal was met.
“Masakit yung breastfeeding pregnancy, nursing - Establish - This would The patient
utong ko. related to mothers are intervention, the therapeutic nurse- allow both showed
Mahapdi, improper naturally patient will be client relationship. patient and satisfactory with
ganyan, kada breastfeeding engaged to able to nurse to be able regards to
dumedede siya position and breastfeeding understand the to trust and be breastfeeding
(the baby) technique their babies and importance of comfortable with and also
parang for some proper one another. understood the
bumubuka yung reasons the breastfeeding - Encourage the - To measure importance of
balat sa gitna ng common cause techniques and patient to verbalize and determine proper
utong ko, yung of pain and be able to her feelings the knowledge breastfeeding
nilalabasan ng irritability in demonstrate of patient technique.
gatas,” as breastfeeding is correctly. regarding
verbalized by the improper breastfeeding.
the patient. latching and/or - Give proper health - To be able to
positioning of teaching about demonstrate
Objective: the baby. breastfeeding proper
- slightly irritated positions. breastfeeding
- facial comfortably and
grimacing while References: effectively.
breastfeeding - - Instruct the patient - To be able for
- cracked babycenter.com to nurse on the less the injured area
th
nipples on left - NANDA 13 ed injured area first to heal or be at
breast (Doenges et al., with proper rest.
- poor 2013) technique.
concentration or - Advice patient to - Using warm,
focus on briefly apply warm moist
breastfeeding compress at first compresses or
- pain scale of then, apply cold taking a warm-
4/10 compress to her hot shower with
- V/S are as breasts after gentle breast
follows: feedings for 15-20 massage can
BP: 120/90 minutes. help the milk
mmHg flow. Cold
RR: 19cpm compress can
PR: 82bpm reduce swelling
T: 36.9 C and
inflammation.
- Encourage skin to - To allow
skin contact with mother and baby
newborn and bonding which
increase time of can initiate
breastfeeding. proper latching.
- Instruct patient of - To allow the
proper hygiene breast to heal
especially in the quickly, also to
breast such as avoid infections
cleaning the area and maintain a
before and after clean feeding
breastfeeding. environment for
the newborn.