NURSING CARE PLAN NO.

4 Date Identified: November 29, 2008
CUES Objective Cues: • Has not yet taken a bath due to beliefs • Nails were untrimmed several dirt underneath • Guards her abdomen frequently as seen NURSING DIAGNOSIS Risk for infection r/t traumatized skin tissue 2º cesarean section OUTCOME CRITERIA Short Term Goal: Within 8º of nursing interventions, the patient will be able to identify interventions to prevent/reduce the risk of infection NURSING INTERVENTIONS • Assess the client’s vital signs • RATIONALE This will serve as a baseline data, and will help us identify any abnormalities if one of these signs are altered. Signs and symptoms reflect the severity of the underlying condition Hand washing is known to be a first line defense against infections Increasing fluid intake and eating of foods rich in protein will facilitate wound healing This is done to decrease tissue demands thus preventing fatigue EVALUATION After 8º of nursing interventions, the patient was able to identify measures to prevent infection as manifested by client’s verbalization of: “Muinom nakog daghan tubig, mukaon nakog mga pagkaon na taas ug protina para dali ra mayo akong samad. Manghugas ko ug maayo sa kamot aron dili musamot akong samad.”

Assess for any localized signs and symptoms of infection. Stress to patient the importance of proper hand washing specially when in contact with wound Encourage to increase fluid intake at least 8 oz per hour and eat protein-rich foods such as meat and beans Encourage to take adequate rest periods

• Long Term Goal: Within 3 days of nursing interventions, the patient will be able to demonstrate lifestyle changes to promote safe environment

Emphasize the necessity of taking antibiotics AS DIRECTED

To eradicate infection causing microorganisms

COLLABORATIVE: • Administer antiinfectives per prescription

NURSING CARE PLAN NO.5 Date Identified: November 29, 2008
CUES Objective Cues: • Patient has not yet eliminated since delivery • Absence of bruit sounds • Normal pattern of bowel has not yet returned NURSING DIAGNOSIS Risk for constipation r/t post pregnancy 2° cesarean section OUTCOME CRITERIA Short Term Goal: Within 8º of nursing interventions, the patient will be able to demonstrate behaviors or lifestyle changes to prevent developing problem NURSING INTERVENTIONS INDEPENDENT INTERVENTIONS: • Ascertain normal bowel functioning of the patient, about how many times a day does she defecate Encourage intake of foods rich in fiber such as fruits RATIONALE EVALUATION After 8º of nursing interventions, the patient was able to identify measures to prevent infection as manifested by client’s verbalization of: “Muinom nakog daghan tubig ug mukaon nakog mga prutas aron makalibang nakog insakto..”

This is to determine the normal bowel pattern To increase the bulk of the stool and facilitate the passage through the colon To promote moist soft stool

• Long Term Goal: Within 3 days of nursing interventions, the patient will be able to maintain usual pattern of bowel functioning

Promote adequate fluid intake. Suggest drinking of warm fluids, especially in the morning to stimulate peristalsis Encourage ambulation such as walking within individual limits

To stimulate contractions of the intestines and prevent post operative complications

However, since she has had cesarean, also encourage adequate rest periods

To avoid stress on the cesarean incision/ wound

COLLABORATIVE:

Administer bulkforming agents or stool softeners such as laxatives as indicated or prescribed by the physician

To promote defecation

NURSING CARE PLAN NO.2 Date Identified: November 29, 2008
CUES Subjective Cues: “Kana rang commercial na gatas akong ginapatotoy nako sa akong kamagulang an..” Objective Cues: • NURSING DIAGNOSIS Deficient Knowledge r/t lack of interest in learning OUTCOME CRITERIA Short Term Goal: Within 8º of nursing interventions, the patient will be able to participate in learning process NURSING INTERVENTIONS INDEPENDENT INTERVENTIONS: RATIONALE EVALUATION After 8º of nursing interventions, the patient was able to identify measures to prevent infection as manifested by client’s verbalization of: “Patotoyon na nako akong anak nga dili mag gamit ug gi-commercial na mga gatas..”

Identify motivating factors for the patient such as provision of visual aids about breastfeeding Involve client in sharing her thoughts about breastfeeding Encourage patient in indulging herself in discussions about breastfeeding

Client may need visualizations to increase her interest

• Long Term Goal: Within 3 days of nursing interventions, the patient will be able to exhibit increased interest and assume responsibility for own learning and •

Patient knows minimal information about breastfeedin g but takes it for granted Client

Provides time for patient to share her perceptions Done to determine whether she has interest in altering her current manners Also done to instill realizations for her second born child

Emphasize to patient

appears uninterested when information is discussed

begin to look for information and ask questions

the significance of breastfeeding to infants

To let her understand why it is more effective to have feeding from the breasts than bottle-feeds.

DEPENDENT INTERVENTIONS: • Refer patient to support groups in enhancing breast feeding techniques

NURSING CARE PLAN NO.3 Date Identified: November 29, 2008
CUES NURSING DIAGNOSIS OUTCOME CRITERIA NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective Cues: “Magsakit usahay ang tahi..” Objective Cues: • Guards the area of incision frequently Grimace of face Pain scale rate of 2 out of 5

Acute Pain r/t incision at the lower abdomen

Short Term Goal: Within 8º of nursing interventions, the patient will be able to report pain as relieved or controlled

INDEPENDENT INTERVENTIONS: • Assess the vital signs

Any alterations occurring in v/s may indicate presence of pain To determine the degree or severity of pain

• •

Long Term Goal: Within 3 days of nursing interventions, the patient will be able to verbalize methods that provide relief •

Let patient rate pain in a scale of 1-5, having 5 as the highest possible pain, and one as the lowest Encourage patient to use diversional activities such as reading of magazines, watching television\ or listening to radio Teach breathing and coughing exercises Promote adequate rest periods

After 8º of nursing interventions, the patient was able to identify measures to prevent infection as manifested by client’s verbalization of: “Nawala naman pud ang sakit..”

These activities may divert the patient’s attention from perceiving pain

• •

• •

To promote relaxation To prevent further stress or fatigue to the wound Analgesic inhibit the pain receptor mechanism

DEPENDENT: • Administer analgesics as ordered NURSING CARE PLAN NO.1

Date Identified: November 29, 2008

CUES Subjective Cues:

NURSING DIAGNOSIS Imbalanced Nutrition: More than Body requirements r/t excessive intake in relationship to metabolic need

OUTCOME CRITERIA Short Term Goal: Within 2 weeks of nursing interventions, the patient will be able to demonstrate appropriate lifestyle changes including behaviors on eating patterns, food quality/quantity and exercise program

NURSING INTERVENTIONS INDEPENDENT INTERVENTIONS: • Ascertain patient’s knowledge about appropriate food intake Set goals with the patient in establishing nutritious dietary intake Discuss with client the possibility of weight loss Discuss with patient the nutritious foods that could help her body and mind function well such as the emphasis of the Go, Grow and Glow foods Encourage patient to establish a routinely exercise program by herself

RATIONALE

EVALUATION

Thick skin folds were noted located near the armpit Patient’s weight is more than the normal weight of a pregnant woman, about 183 lbs Frequently complains about hunger

To identify the patient’s pattern of eating To increase patient’s motivation Helps client determine realistic motivating factors Patient might have the ideas of these food groups but might be taking it for granted

Long Term Goal: Within 2 months of nursing interventions, the patient will be able to attain desirable body weight with optimum maintenance of health

To help lose weight and keep the body in tone to promote optimum functioning of the body systems Rendering good information about what to avoid will

Encourage patient to avoid eating foods rich in cholesterol and sodium that may increase the tendency of obesity and other health problems such as cardiovascular dysfunctioning and obesity

help patient identify the right kind of foods to eaten. Healthful and nutritious

DEPENDENT INTERVENTIONS: • Refer patient to dieticians and exercise programs of these independent interventions fail

Seeking for professional help may help the patient achieve her goals

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