Arellano, Aigina Lucelle H BSN 2

March 4, 2012

Patient: Mrs de Leon Case: Post partum (Cesarean Section)

ASSESSMENT
Subjective: - Medyo masakit ang aking tahi as verbalized by patient.

NURSING DIAGNOSIS
Acute Pain related to Tissue Trauma secondary to Cesarean Section

PLANNING
Within 8 hours of rendering appropriate nursing intervention, the Patient will be able to know different measures to alleviate pain such as proper breathing techniques as manifested by the pain scale 3 from 6 with 10 as the most painful.

INTERVENTION

RATIONALE

EVALUATION
Within 8 hours of rendering appropriate nursing intervention, the Patient had known different measures to alleviate pain such as proper breathing techniques as manifested by the pain scale 3 from 6 with 10 as the most painful.

-teach relaxation technique like deep breathing.

-to reduces tension and anxiety, which potentiates the perception of pain

Objective: - received patent lying on bed, resting -pain scale -6 -guarding behavior -experienced pain while moving -irritability -v/s: BP- 100/70 T- 36 RR- 79 PR- 79

- encouragepatient to have adequate bed rest periods.

-bed rests decreasesbody metabolism and thus reduces muscle tension.

-monitor v/sand pain scale

-to obtain baseline data of the patient and to rule out worsening of underlying condition development of complication

-maintained a therapeutic and quiet environment.

-to provide comfort for the patient

-administered the medication ordered by the doctor.

-to alleviate pain of the client.

Arellano, Aigina Lucelle H BSN 2

March 4, 2012

Patient: Mrs. Sy Case: Post partum (Cesarean Section)

ASSESSMENT
Subjective: - Wala po bang mga bawal na pagkain sa akin na baka makasama sa anak ko as verbalized by patient.

NURSING DIAGNOSIS
Knowledge Deficit related to limited experience and skill in providing infant care after giving birth.

PLANNING
Within 8 hours of Nursing Intervention, the client will be able to gain cognitive knowledge and psychomotor skills needed for infant care as evidenced by: a.verbalization of understanding of infant care instructions b.exhibit increased interest/assume responsibility for own learning by beginning to look for inform ation and ask questions

INTERVENTION

RATIONALE

EVALUATION
Within 8 hours of Nursing Intervention, the client had gained cognitive knowledge and psychomotor skills needed for infant care as evidenced by: a.verbalization of understanding of infant care instructions b.exhibit increased interest/assume responsibility for own learning by beginning to look for inform ation and ask questions

-Encourage client to breast feed her baby and inform client advantages

-to protect the baby from infection against illness, from allergies and for the mothers benefits such as it promotes post partum weight loss and delayed fertility

-Discuss

Objective: - first time mom -17 years old mother -poor hygiene(not properly dressed) -low selfesteem) -education attainmenthigh school undergraduate

the need for interactive nature of bonding.

-helps client to understand significance and importance of mother and child bonding

-Teach client drink 8-10 glasses of water per day and eat nutritious diet such as fresh fruits and vegetables, fiber, proteins and vitamin C.

- Information helps the client to plan for adequate nutrition for recovery from childbirth.

-Provide information for breast-feeding mothers about extra fluids needed such as soup of malunggay.

-Nursing mother require extra calories and fluids to produce milk and meet their own needs.

-Encourage client to avoid strenuous activities or exercise such as bringing heavy materials and playing sports for six weeks.

-strenuous exercise may cause postpartum hemorrhage before the placental site is healed

Arellano, Aigina Lucelle H BSN 2

March 4, 2012

Arellano, Aigina Lucelle H BSN 2

March 4, 2012

Patient: Mrs. Fernandez Case: Acute Appendicitis (gyne)

ASSESSMENT
Subjective: - hirap akong gumalaw kasi masakit yung inoperahan sakit as verbalized by patient.

NURSING DIAGNOSIS
Impaired physical mobility related to RLQ exploration

PLANNING
Within 8 hours of Nursing Intervention, the client the patient will be able to maintain or increase strength and function of affected and compensatory body part

INTERVENTION

RATIONALE

EVALUATION
Within 8 hours of Nursing Intervention, the patient had maintained or increased strength and function of affected and compensatory body part.

- Assisted/have client reposition self on a regular schedule from side to side

-To decrease numbness and pain in the affected area.

- Used side rails of bed

Objective: - limited ROM -grimace face noted -restlessness -difficulty in turning -lying down on her bed -with IVF D5LR with IV meds

-To prevent the patient from possible fall or accident that might happen.

- Encouraged patient to take few steps a day

- This will help the patient to mobilize and recover faster

-Monitored IVF.

-to assure that medication is given properly.

-Administered the medication ordered by the doctor

-to relieve pain of the patient.

Arellano, Aigina Lucelle H BSN 2

March 4, 2012

Arellano, Aigina Lucelle H BSN 2

March 4, 2012

Patient: Mrs. Adecer Case: Normal Spontaneous Delivery

ASSESSMENT

NURSING DIAGNOSIS
Risk for Infection related to breakage of first line defense (skin) secondary to episiotomy

PLANNING
Within 8 hours of rendering appropriate nursing intervention, the Patient will be able to manifest absence of infection through maintaining VS within normal range: Temperature:35.636.7oC, BP: 110/70130/90mmHg, PR: 80-90, RR: 16-20bpm; a. absence of foul odor in incision site. b. verbalize the importance of proper perineal care in preventing perineal infections

INTERVENTION

RATIONALE

EVALUATION
Within 8 hours of rendering appropriate nursing intervention, the Patient had able to manifest absence of infection through maintaining VS within normal range: Temperature:35.6-36.7oC, BP: 110/70-130/90mmHg, PR: 80-90, RR: 16-20bpm; a. absence of foul odor in incision site. b. verbalize the importance of proper perineal care in preventing perineal infections

Objective: - wears perineal pad -has episiotomy -vital signs as follow: BP-110/70 T-36.5 oC PR- 71 RR-15

- Demonstrate the
proper way of hand washing.

- handwashing is the first-line defense from acquiring infections

- Encourage patient to wash her hands after handling pads and use only her personal equipment.

- these actions prevent the patient from contracting or spreading infection

-monitor v/s

-to obtain baseline data of the patient and to rule out worsening of underlying condition development of complication

-Maintain a clean environment: ensure that housekeeping has cleaned the room, equipment and bathroom; empty trash as needed. . -Monitor temperature and pulse.

-cleaning prevents the spread of nosocomial infections within the hospital.

-increase in temperature and maternal tachycardia may indicate infection

Arellano, Aigina Lucelle H BSN 2

March 4, 2012

Patient: Mrs. Francisco Case: Normal Spontaneous Delivery

ASSESSMENT
Subjective: - Gutom siguro ang anak ko kaya umiiyak as verbalized by patient.

NURSING DIAGNOSIS
Ineffective Breastfeeding r/t Poor Infant Sucking Reflex

PLANNING
Within 8 hours of rendering appropriate nursing intervention, the baby will be able to stop crying and will show satisfactory response to breastfeeding process

INTERVENTION
>Explain the benefits of breast feeding, the mechanisms involve in lactation, the proper breast care and most especially the proper breast Feeding position. >Assist the breastfeeding process as needed

RATIONALE
>to promote breast feeding because breast milk contains all the necessary nutrients a baby needs for the first 6 months of life

EVALUATION
Within 8 hours of rendering appropriate nursing intervention, the baby had able to stop crying and showed satisfactory response to breastfeeding process

Objective:
-infant refrain from sucking the mothers nipple even if shes crying -mother is the one inducing to baby to breastfeed -infant sucks milk in a minimal amount -infant cries most of the time

>to promote bonding between mother and child

> Increase fluid intake

>Breastfeeding delays ovulation and therefore the possibility of another pregnancy

>Discuss the importance of adequate nutrition during lactation

>Breastfeeding helps stop bleeding after delivery

Arellano, Aigina Lucelle H BSN 2

March 4, 2012

Patient: Mrs. Oleno Case: Normal Spontaneous Delivery

ASSESSMENT

NURSING DIAGNOSIS
Impaired Parenting r/t altered perceptual abilities

PLANNING
Within 8 hours of rendering appropriate nursing intervention, the Patient will be able to demonstrate appropriate attachment behaviour towards the child by doing breast feeding

INTERVENTION

RATIONALE

EVALUATION
Within 8 hours of rendering appropriate nursing intervention, the Patient had able to demonstrate appropriate attachment behaviour towards the child by doing breast feeding

Objective:

- Discuss parental beliefs about child bearing and teaching about punishments

- allows opportunities to provide new information regarding not using spanking

-mother does not practice burping after her baby drinks milk from the bottle.
-mother leaves the baby with the relatives -mother did not immediately anticipate the needs of the baby (she just let her baby cry)

- Acknowledge difficulty of situation and normalcy of feelings.

- Enhances feelings of acceptance.

-Teach proper way of breast feeding

-to promote bonding between mother and the baby

-Observe attachment behaviours between parental figure and child. -Acknowledge difficulty of situation and normalcy of feelings.

- it may affect attachment and care taking needs

-Enhances feelings of acceptance.

Arellano, Aigina Lucelle H BSN 2

March 4, 2012

Patient: Mrs. Ison (Gyne)

ASSESSMENT

NURSING DIAGNOSIS
Risk for Defecient Fluid Volume related to improper IVF regulation

PLANNING
Within 8 hours of rendering appropriate nursing intervention, the Ptient will be able to maintain and demonstrate improved fluid balance, as evidenced by adequate urine output, stable vital signs, and good skin turgor.

INTERVENTION
>Monitor VS and skin turgor

RATIONALE
>indicators ofadequacy of circulating volume.

EVALUATION
Within 8 hours of rendering appropriate nursing intervention, the Ptient had able to maintain and demonstrate improved fluid balance, as evidenced by adequate urine output, stable vital signs, and good skin turgor.

Objective: -IVF does not flow properly -weakness -decreased BP VS as follows: BP: 100/70 T:36 PR:79 RR:25

>Monitor amount and types of fluid intake. Measure urine output.

>client may abstain from all intake with resulting disturbed electrolytes balance

> Monitor IVF regulation

>to make sure that the fluid administered by the patient is accurate

>Identify actions necessary to regain or maintain optimal fluid balance, such as specific fluid intake schedule.

>involving client in plan to correct fluid improves chances for success