Cues Nursing Diagnosis Planning Nursing Rationale Evaluation

Interventions
S- “sakit ahong Pain related to After 8 hours of Independent: 1. A client Patient’s pain scale
tinahian” as surgical wound appropriate experiencing pain is decreased from 7
verbalized by the secondary to CS nursing Elaborate with may feel a loss of to 2 or 3 and
patient. delivery. intervention, the client to determine control over her expresses comfort
patient’s pain will effective pain relief body and her life. as evidenced by
O SCIENTIFIC be decreased to 2- interventions. Collaboration can absence of facial
-can rate pain scale BASIS: 3 from pain scale help minimize this grimaced,
of 7/10 (10-highest, of 7/10 Explain and assist feeling. ambulate
0-absence of pain) Pain sensations are with non-invasive effectively and
influenced by Specific and non- 2. These measures having
- grimaced face inherent control outcomes: pharmacologic pain can help to reduce conversation with
noted systems. Rubbing relief measures: pain by her husband
-guarding behavior the skin in the area a. Rate pain as substituting comfortably.
observed of an injury 2 or 3 with a. proper another stimulus
stimulates the 10= severe positioning to prevent painful
- with ff. initial tactile receptors, pain and 0= b. breathing stimuli from
vital sign of: which send action no pain. exercise reaching higher
potentials along b. Absence of c. massage brain centers.
T- 37 degree the sensory axons facial d. heat and cold
Celsius to the spinal cord. grimace. application. 3. These measures
P-79bpm c. Ambulate can help to reduce
R- 22cpm effectively. Assist client in anxiety and regain
BP-120/80mmHg coping with the sense of control.
SOURCE: Seeley, pain experience:
-limited ambulation Med et al; 4. Narcotics can
Essentials of a. Encourage depress the
anatomy and patient to discuss respiratory center
Physiology; 6th the experience. of the brain.
Edition; McGraw-
Hill Inc., © 2007; d. Praise the
p.245 patient for her
endurance and
behavior.
Dependent:

Provide optimal
pain relief with
prescribed
analgesics:

a. assess vital
signs- especially
respiratory rate.
 Cues Nursing Diagnosis Planning Nursing Rationale Evaluation
Interventions
S “ Init – init High risk for After 8 hrs of • Minimizing Patient is free
kanunay ahong infection related appropriate Independent: moisture in from infection as
paminaw. ” to surgical wound nursing • Teach the the wound evidenced by
as verbalized by secondary to CS intervention the patient to decreases normal skin
the patient. delivery. patient will exhibit position the risk for surface heat of
wound healing body so that infection. affected site.
O Scientific basis: and free from no skin
 Skin is warm infection. surfaces • Air will help
to touch Infections can come in to dry the
occur in the Specific outcome: contact with wound.
 flushed skin mother or infant, each other.
noted or both; maternal Decrease skin • Expose the • Graft failure
death associated surface heat on wound to air can result
 Pallor both with childbirth can affected site. for 15 min. from a wound
extremities result from periods infection.
noted infections. during the
Cleanliness day. • Proper
 Pallor lips associated with • Teach client hygiene
noted childbirth the decreases
procedures can importance the risk for
reduce the rate for of avoiding
 Diaphoresis infection.
infection, and wound
noted
antibiotics have maceration • To alleviate
greatly reduced and graft
has wound in the fever through
the number of infection.
abdominal area due central action
fetal infections.
to cesarean section • Encourage in the
delivery the client hypothalamu
Source:
the s.
Steeley, Med et al;
importance
Essentials of
of personal
Anatomy and
hygiene
Physiology; 6th
(douche).
Edition, McGraw –
Hill Inc., @ 2007, p
588. Dependent:
Administer
antipyretic drugs as
prescribed.
 Cues Nursing Diagnosis Planning Nursing Rationale Evaluation
Interventions
Moderate anxiety After 3 hrs of - Give patient - To inform about Patient verbalized
S “Sir, kuyawan related to unknown appropriate clear, concise possible ways in eliminating
jud ko kay e outcome of nursing explanations intervention. and minimizing
operahan daw ko upcoming surgical intervention the regarding anxious behaviors
ingon ang doktor” procedure patient will be able upcoming and demonstrates
as verbalized by to identify factors operation progressive
the patient. Scientific basis: that elicit anxious - To allow patient relaxation
behaviors, practice - Listen attentively, to identify anxious techniques.
O It is an anticipation progressive allow patient to behaviors and
 Received of impending relaxation express feelings discover source of
client at danger and dread techniques and will verbally. anxiety
Gyne Phil- accompanied by have an
Health, restlessness, understanding of -Provide a calm - To reduce
sitting on tension, the upcoming and relaxing environmental
the chair, tachycardia and operation as environment for stressor as possible
awake, breathing difficulty explained by the patient
conscious not necessarily physician.
associated with an - Have patient - This gives patient
 BP= 120/90 apparent stimulus. Specific outcome: state what kind of a sense of control
mmHg activities to
SOURCE: Demonstrate promote of feelings
 Frequent MOSBY’S POCKET relaxation of comfort and
questioning DICTIONARY OF technique such as encourage patient
regarding MEDICINE, deep breathing to perform them.
upcoming NURSING & thus minimizing - To allow anxious
operation HEALTH anxiety. - Allow extra patient and family
noted PROFESSIONS. visiting periods to support each
with family if this other according to
 Decreased seems to allay their abilities and
perceptual patient’s anxiety. at their own pace.
field noted

Diaphoresis noted