Date/Time April 25, 2011 3-11 4:30pm

Cues Subjective: Nagasakit ang akong tahi labi na pag molihok ko as verbalized by the client Objective: 3 days post op Protective behaviour Uncomfort able Grimmace face Pain scale of 7 out of 10 (1-3 as mild, 4-7 as moderate, 8-10 as severe) Presence of wound dressing, dry and intact

Needs C O G N I T I V E P E R C E P T U A L P A T T E R N

Nursing Diagnosis Acute Pain related to Presence of Surgical Incision secondary to Cesarean Section The client is experiencing pain due to the episiotomy done to her after the CS operation.

Objective of Care Within the 6 hours span of nursing care and management , the patient will be able to: a. Reliev e from pain

Nursing Intervention 1. Note location of surgical procedure as this can influence the amount of postoperative pain experienced

Evaluation GOAL MET @ 9:30PM Patient was able to: a. Reliev ed from pain as verbali zed Dili nman kayo sakit makay a lng sya
b. Be in

2. Assess clients pain using a scale of 1-10 with 1 being least, 10 being most. Assessment b. Verbal provides objective ize measurement of the comfor clients perception of t pain. 3. Observe client for nonverbal signs of pain; grimacing, guarding, pallor, withdrawal. Observation helps identify discomfort when the client doesnt ask for help.

a comfor table situatio n as eviden ced by sleepin g and moving without

 Body temp of 38.1 C Elevated WBC result of 26.79

4. Assess location and character of pain each time the client reports discomfort. Assessment provides info about the cause of pain. Unusual pain may indicate complications. 5. Monitor vital signs and record. Pain may alter patients condition. 6. Provide comfort measures such as back rub To promote non pharmacological pain management 7. Instruct in/encourage use of relaxation technique such as deep breathing exercises. To distract attention and reduce tension

assista nce

8. Encourage diversional activities(socializatio n of others) These enable the patient not to concentrate on the pain that shes experiencing. 9. Encourage verbalization about the pain. So that relief measure may be instituted 10. Give analgesics (Ketorolac) as ordered, evaluating effectiveness and observing for any signs and symptoms of untoward effects. Pain medications are absorbed and metabolized differently by patients.

Date/Time April 26, 2011 3-11 5:00pm

Cues Subjective: Nagdako jud akong tiil, as verbalized by the patient Objective: Edema on both feet Elevated sodium level of 137 Urine specific gravity of 1.015

Needs N U T R I T I O N A L M E T A B O L I C P A T T E R N

Nursing Diagnosis Excess fluid volume r/t increase sodium level both water and sodium are gained in about the same proportions as normally exists in extracellular f luid. The total body sodiumconten t is increased, which in turncauses an increase in total body water. Reference: Sparks and Taylors Nursing Diagnosis

Objective of Care Witihin 5 hours of nursing care, patient will be able to: a. Have good skin integrity b. Remain the weight as the same

Nursing Intervention 1. Monitor and record vital signs at least every 4 hours. : Changes may indicate fluid or electrolyte imbalances. 2. Measure and record intake and output. : Intake greater than output may indicate fluid retention and possible overload. 3. Weigh patient at same time each day. : To obtain consistent readings.

Evaluation GOAL UNMET @9:45PM Patient was able to: a. Have a good skin integrity as evidenced by good skin turgor b. Remain her weight

4. Administer diuretics : To promote fluid excretion. 5. Maintain patient on sodium restricted diet, as ordered. : To reduce excess fluid and prevent reaccumulation 6. Reposition patient every 2 hours, inspect skin for redness with each turn, and institute measures as needed. : Prevent skin breakdown.

7. Encourage patient to cough and deep breathe exercise : To prevent pulmonary complications. 8. Educate patient regarding maintenance of daily weight record, daily measuring and recording of intake and output, diuretic therapy, and dietary restrictions, especially sodium. :These measures encourage Patient to participate more fully.

Date/Tim e April 25, 2011 3-11 4:30pm

Cues Subjective: kapoyan ko maglihok kay musakit akong tahi. as verbalized by the client Objectives: Needs assistance in doing activities Cautious in initiating position changes Limited range of motion.

Need s A C T I V I T Y E X E R C I S E P A T T E R N

Nursing Objective of Diagnosis Care Activity Within the 6 hours intoleranc span of nursing e related care and to management, the incisional patient will: discomfort a) Perform and use energyExtremed conservationfatigue or techniques. other physical b) Participate symptoms willingly in caused by necessary/desired simple activities. activity Reference : Sparks and Taylors Nursing Diagnosis

Nursing Intervention 1. Note client reports of pain and difficulty accomplishing tasks. Symptoms may be result of/ or contribute to intolerance of activity. 2. Evaluate clients actual and perceived limitations/degree of deficit in light of usual status. Provides comparative baseline and provides information about needed education/intervention s regarding quality of life. 3. Ascertain ability to stand and move about and degree of assistance necessary/use of equipment.

Evaluation GOAL MET @ 8:30 PM Patient was able to: a) Used energy conservation techniques s evidenced by alternating rest in periods of tme. b) Participated willingly in necessary/desired activities.

 To determine current status and needs associated with participation in needed/desired activities. 4. Encourage client to maintain positive attitude; suggest use of relaxation techniques, such as visualization/guided imagery, as appropriate To enhance well being 5.Instruct the patient to ambulate as tolerated this promotes better wound healing 6. Assist with activities and provide/monitor clients use of assistive devices or use of assistance from others. To protect client

from injury 7. Promote comfort measures and provide for relief of pain to enhance ability to participate in activities 8. Assist the patient with self care activities as needed. Let the patient determine how much assistance is needed Allows the patient to have some control and choice in plan; helps the patient to gradually decrease the amount of activity intolerance. 9. Provide positive atmosphere, while acknowledging difficulty of the situation for the client. helps to minimize frustration, rechannel energy.

10. Have specific times set for visiting of friends or relatives to conserve energy

Date/Tim e April 28, 2011 3-11 4pm

Cues Subjective/ Objective: 6days post CS (+) wound dressing - dry and intact - no secretion - no swelling - no redness Length of incision: 4inches Temp = 38.3 C

Need s H E A L T H P E R C E P T I O N H E A L T H M A N A

Nursing Diagnosis Risk for infection related to surgical incision Accentuat ed risk of invasion of a surgical wound by a pathogeni c organism (bacteria, virus, fungus, protozoa, or parasite) from either endogeno us or environme ntal sources

Objective of Care Within the span of 6 hours of shift, patient will be able to remain free of infection, as evidenced by: a) normal temperatur e b) absence of purulent drainage from incisions c) incision is free of redness, swelling

Nursing Intervention 1. Encourage patient with a total bed bath daily reduces microorganism on the skin 2. Wash your hands thoroughly between each treatment Prevents cross contamination of microorganisms. 3. Teach the patient the value of frequent hand washing Prevents cross contamination and nosocomial infections. 4. Use universal precautions and teach the patient the purpose and techniques of universal precautions such as hand washing technique.

Evaluation GOAL MET @ 8:45PM Client was able to remain free of infection, as evidenced by: a) Temp = 36.3 C b) absence of purulent from incisions and c) incision was free of redness, swelling

G E M E N T P A T T E R N

Reference : Sparks and Taylors Nursing Diagnosis

Protects the patient from infection 5. Maintain adequate nutrition and fluid and electrolyte balance Helps prevent disability that would predispose infection 6. Encourage ambulation, deep breathing, coughing, position change for mobilization of respiratory secretions 7. Teach the patient about the infectious process, route, pathogens, environmental and host factors and aspects of prevention. Provides basic knowledge for self help and self protection

8. Teach client to wash hands frequently, especially after toileting, before meal, and before and after administering self-care. Clients can spread infection from one part of the body to another, as well as pick up surface pathogens, hand washing reduces these risks. 9. Assess dressings or incisions, noting if dressing clean, dry and intact, if incisions exhibit redness, edema, ecchymosis, drainage and approximation. Assessment provides information about developing infection. Local inflammatory effects cause of redness and

edema. This may be followed by purulent drainage and around dehiscence. 10. Provide patient abdominal binder it is a support device for a patient with an open incision

Date/Tim e April 26, 2011 3-11 5:00pm

Cues Objectives: Expressed fear of unspecified negative outcome; feelings of helplesness or incapacity Presence of sweating

Need s S E L F P E R C E P T I O N S E L

Nursing Diagnosis Anxiety r/t change in health status Vague, uneasy feeling of discomfort or dread accompan ied by autonomic response. Reference : Sparks and Taylors Nursing Diagnosis

Objective of Care Within 4 hours of nursing intervention the patient will be able to:

Nursing Intervention

Evaluation GOAL MET @ 8:00PM Patient was able to: Patient acknowledged feelings and identifies

1. Facilitate development as a trusting relationship with patient and family Trust is necessary before patient and a. Acknowled family can feel free the ge feelings open personal lines and identify and communication healthy with hospice team and ways to address sensitive deal with issues. them. 2. Be available to client for listening and talking to assist client in identifying feelings and begin to deal with problems. 3. Clarify meaning of feelings/actions by providing feedback and checking meaning with the client. to assist the client to identify feelings

F C O N C E P T 3. Provide open, nonjudgmental environment. Use therapeutic communication skills. Promotes and encourage dialogue about feelings and concerns. 4. Encourage verbalization of thoughts and concerns and accept expressions of sadness and anger. Patient may feel supported expression of feelings by understanding that deep and often conflicting emotions are normal in this situation. 5. Provide accurate information about the situation helps the client identify what is reality

based.

6. Reinforce teaching regarding disease process and treatments and provide information as requested. Be honest; do not give false hope while providing emotional support. Patients benefit from factual information. Honest answer promotes trust. 7. Assist the patient in developing anxietyreducing skills Using anxietyreduction strategies enhances patients sense of personal mastery and confidence.

8. Emphasize the logical strategies patient can use when experiencing anxious feelings. Learning to identify a problem and evaluate alternatives to resolve it helps the patient to cope 9. Assist patient in recognizing symptoms of increasing anxiety; explore alternatives to use to prevent the anxiety from immobilizing her or him The ability to recognize anxiety symptoms at lowerintensity levels enables the patient to intervene more quickly to manage his or her anxiety. Patient will be effectively when the level of anxiety is low.

10. Instruct patient in the proper use of medications and educate him to recognize adverse reactions Medication may be used if patients anxiety continues to escalate.