ASSESSMENT Subjective: ³Makirot ang hiwa ko sa tiyan, lalo na pag umuupo ako,´ as stated by the patient.

8 out of 10 pain scale

NURSING DIAGNOSIS

PLANNING Within 20 minutes of nursing intervention, the patient will be able to:  Participate in demonstrating techniques to relieve pain  Verbalize eliminatio n/reduction of pain from 8 to 4. INDEPENDENT

IMPLEMENTATION DEPENDENT COLLABORATIVE

EVALUATION After 20 minutes of nursing intervention, the client: Demonstrated participation in techniques to relieve pain (proper positioning, resting, and following nonpharmacologi c pain regimens) Verbalized reduction of pain from 8 to 5 Goal partially met.

Acute pain
related to abdominal incision as evidenced by 8 out of 10 pain scale

Objective: Vital Signs ± BP ± 110/90 mmHg PR ± 80 bpm RR ± 24cpm Temp ± 37.4°C Incision Site ± Wound dressing intact S/Sx ± Expressive behavior: irritability, facial grimacing Covers the incision site (guarding behavior) No foul odor noted Incision site warm and reddened

Assess:  Assess client¶s pain scale (to be able to monitor progression of nursing interventions)  Monitor vital signs every 4 hours Care:  Provide calm, quiet environment  Provide comfort measures such as back rub (to provide nonpharmacological pain management)  Promote low Fowler¶s position (low Fowler¶s position reduces intraabdominal pressure, thus reduces pain too)  Employ nonpharmacologic pain distraction such as music therapy, watching television, and talking to SOs. (distraction of attention reduces pain perception) Teach:  Teach client to eat fresh 

Administer mefenamic acid q4° PO (taking analgesics lessens the pain) 

Encourage

fruits vegetables and also to increase protein and fluid intake in the diet (intake of foods that promote wound healing hastens healing of client¶s wound, thus reduce and eliminate pain from it)  Encourage adequate rest periods (to prevent fatigue)

ambulation as soon as possible after birth (ambulati on decreases venous stasis and increase platelets that canpromo te wound healing)

ASSESSMENT Subjective: n/a Objective: Incision site ± 7 cm horizontal hypo-gastric incision with intact sutures Open area moderate amount of serosaguineous drainage No odor, skin around erythematous Pain 8 out of 10 scale

NURSING DIAGNOSIS

PLANNING After 3 days of nursing intervention, the patient will be able to: Display gradual and timely healing on the incision site Participate in prevention measures that can hider wound healing and treatment program

IMPLEMENTATION INDEPENDENT Assess:  Assess the appearance, odor, and drainage in the incision site (for documentation purposes and also serves as the baseline data for future comparison) Care:  Perform hand hygiene before touching the incision site (to prevent spread of microorganisms)  Keep the area of incision site clean and dry, carefully dress wound, and support incision (to assist body¶s natural process of healing)  Use appropriate wound coverings and skin-protective agents (to protect the wound and surrounding areas/structures from trauma, injury, and microorganisms) Teach:  Assist the client/SOs in understanding and following medical regimen and developing program of preventive care and daily maintenance (enhances commitment to plain, optimizing outcomes)  (with MD) Administe r cephalexin 500mg PO q6° to prevent infection  (with nutritionis t) Provide optimum nutrition and increased protein intake to provide a positive nitrogen balance (to aid in healing and to DEPENDENT COLLABO RATIVE

Impaired skin integrity
related to surgical incision as evidenced by 7 cm incision around hypogastric area

EVALUATION After 3 days of nursing intervention, the patient was able to: Display gradual and timely healing on the incision site. Participate in prevention measures that can hinder wound healing and treatment program 

Teach the client on proper wound dressing (to prevent accumulation of microorganism on the incision site, and enhance independence)  Encourage early ambulation/mobilize-tion (promotes circulation and reduces risks associated with immobility)

maintain general good health)

ASSESSM ENT Subjective: ³Hindi pa ako nakakadumi,´ as verbalized by the client. Objective: (+) hypoactive bowel sounds Medications ± Ferrous sulfate Mefenamic acid

NURSING DIAGNOSIS

PLANNING Within 8 hours of nursing interventions, the patient will be able to establish and regain normal pattern of bowel function INDEPENDENT

IMPLEMENTATION DEPENDENT COLLABORATIVE

EVALUATION After 8 hours of nursing intervention, the client was able to establish bowel movement. Goal met.

Constipatio n related to
decreased gastrointestina l motility as evidenced by hypoactive bowel sounds

Assess:  Record fluid intake and output of the patient (to evaluate hydration status)  Note color, odor, consistency, amount, and frequency of stool (provides aseline comparison and promotes recognition of changes in bowel)  Auscultate abdomen for presence, location, and characteristics of bowels sounds (reflects bowel activity) Care:  Provide sitz bath after stools (for soothing effect to the rectal area)  Administer laxatives (stool softeners), mild stimulants, or bukforming agents to the patient, as prescribed by the physician (to aid the nonpharmacologic nursing interventions in establishing bowel movement)

Teach:  Instruct the patient to increase fluid intake to 1500mL a day (to soften the stool and for hydration)  Instruct in/encourage balanced fiber and bulk in diet (to improve consistency of stool and facilitate passage through the colon)  Promote high fiber fruit juices, and suggest drinking warm, stimulating fluids (to promote moist/soft stool)  Encourage activity/exercise within limits of individual ability (to stimulate contraction of the intestines)

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