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PALAWAN POLYTECHNIC COLLEGE

Manalo Ext, Brgy. Milagrosa Puerto Princesa City

NURSING CARE PLAN


CUES Subjective: Ang sakit ng suga ko sa tyan . As verbalized with pain scale of 7 / 10. Objective:  Restlessness noted  24 days S/P TAH and Exlap  With dressing intact and dry  With abdominal binder  Facial grimace noted  (+) Guarding behavior noted  With ff. V/S: PR-110;RR-28 NURSING DIAGNOSIS Mild Acute Pain R/T Post op surgery OBJECTIVE NURSING INTERVENTIONS INDEPENDENT: 1. Assessed for pain location, intensity, duration and if radiating 2. Monitored vital signs. RATIONALE EVALUATION

At the end of 30 mins. Nursing intervention, she will be able to: Definition:  Reports Unpleasant sensory reduce of pain with and emotional pain scale of experience arising 7/10 to 2/10. from actual or  Identify potential tissue intervention damage or described to reduce in terms of such pain such as damage. relaxation technique and diversional activities.

1. For comparative baseline

3. Positioned patient to comfortable 4. Taught use of diversional activities such as reading and music.

5. Provided and instructed comfort measures such as backrub and deep breathing exercises.

2. Vital signs are usually altered in acute pain episodes. 3. Promote his/her comfort. 4. Relieves muscle and emotional tension; enhances sense of control and may improve coping abilities. 5. Improves circulation reduces muscle tension.

At the end of 30 mins. She had been able to:  Do relaxation technique and diversional activities.  Reported reduce pain with pain scale of 3/10.

PALAWAN POLYTECHNIC COLLEGE


Manalo Ext, Brgy. Milagrosa Puerto Princesa City

NURSING CARE PLAN


CUES Subjective: Naiinip na tlga ako ditto, gusto ko ng lumabas. As verbalized. Objective:  Negative complaints at the incision site  Able to ambulate freely  Able to do ADLs  Admitted for 1 mon and 1 day  Sleepy at times  Lack of materials use for diversional activities NURSING DIAGNOSIS Deficient diversional activities R/T prolonged hospitalization Definition: Decrease stimulation from recreational or leisure activities. OBJECTIVE NURSING INTERVENTIONS INDEPENDENT: 1. Assess physical, cognitive, emotional and environmental status 2. Determined ability to participate / interest in available activities noting physical limitations 3. Acknowledge reality of situations RATIONALE EVALUATION

At the end of 8 hours Nursing intervention, she will be able to:  Engage satisfying activities within personal limitation  Recognize own psychologic al response and initiate appropriate coping actions

4. Encourage verbalization of feelings about present situations. 5. Encourage diversional activities such as talking to other patient 6. Maintain safety by assisting to a comfortable position.

1. To validate reality At the end of 8 of environmental hours nursing deprivation intervention, She had been able to: 2. This may interfere  Participate with desired in activities available activities  Seen 3. To establish talking therapeutic with other relationship and patient. support hopeful emotions 4. Helps to understand what really feels 5. To divert attentions 6. Prevent possible injuries.

PATHOPHYSIOLOGY PREDISPOSING FACTOR Sex Female Age 17 yrs. Old AOG 18 weeks CONTRIBUTING FACTOR > Lifestyle > Lack of support system

PRECIPITATING FACTOR 1 week PTA slide @ the bathroom

Pelvic Pressure

Abnormal Uterine Contraction

Severe Abdominal Pain

Fever; Chilling

Premature Cervical Dilatation

Trauma to the cervix

Vaginal Bleeding