Or/dr Careplans C Evaluation

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

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This will serve as a baseline data, and will help us identify any abnormalities if one of these signs are altered.

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Assess for any localized signs and symptoms of infection.

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Signs and symptoms reflect the severity of the underlying condition

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Stress to patient the importance of proper hand washing specially when in contact with wound

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Hand washing is known to be a first line defense against infections

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Encourage to increase fluid intake at least 8 oz per hour and eat protein-rich foods such as meat and beans

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Increasing fluid intake and eating of foods rich in protein will facilitate wound healing

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Encourage to take adequate rest periods

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This is done to decrease tissue demands thus preventing fatigue

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

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, 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.”

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Emphasize the necessity of taking antibiotics AS DIRECTED

COLLABORATIVE: •

Administer antiinfectives per prescription

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To eradicate infection causing microorganisms

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

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Encourage intake of foods rich in fiber such as fruits

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

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

RATIONALE

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This is to determine the normal bowel pattern

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To increase the bulk of the stool and facilitate the passage through the colon

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To promote moist soft stool

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To stimulate contractions of the intestines and prevent post operative complications

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..”

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To avoid stress on the cesarean incision/ wound

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To promote defecation

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

COLLABORATIVE:

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

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:

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

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:

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Identify motivating factors for the patient such as provision of visual aids about breastfeeding

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Involve client in sharing her thoughts about breastfeeding

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Encourage patient in indulging herself in discussions about breastfeeding

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

RATIONALE

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Emphasize to patient

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Client may need visualizations to increase her interest

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Provides time for patient to share her perceptions

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Done to determine whether she has interest in altering her current manners

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Also done to instill realizations for her second born child

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..”

appears uninterested when information is discussed

begin to look for information and ask questions

the significance of breastfeeding to infants

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

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

NURSING CARE PLAN NO.3 Date Identified: November 29, 2008 CUES

NURSING DIAGNOSIS

OUTCOME CRITERIA

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Subjective Cues:

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“Magsakit usahay ang tahi..” Objective Cues: •

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Acute Pain r/t incision at the lower abdomen

Guards the area of incision frequently Grimace of face Pain scale rate of 2 out of 5

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

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Let patient rate pain in a scale of 1-5, having 5 as the highest possible pain, and one as the lowest

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

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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

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

Date Identified: November 29, 2008

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Any alterations occurring in v/s may indicate presence of pain

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To determine the degree or severity of pain

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

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To promote relaxation

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To prevent further stress or fatigue to the wound

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Analgesic inhibit the pain receptor mechanism

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..”

CUES Subjective Cues:

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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

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

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

NURSING INTERVENTIONS INDEPENDENT INTERVENTIONS: •

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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

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To identify the patient’s pattern of eating

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To increase patient’s motivation

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Helps client determine realistic motivating factors

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Patient might have the ideas of these food groups but might be taking it for granted

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To help lose weight and keep the body in tone to promote optimum functioning of the body systems

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Rendering good information about what to avoid will

EVALUATION

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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

DEPENDENT INTERVENTIONS: •

Refer patient to dieticians and exercise programs of these independent interventions fail

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

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Seeking for professional help may help the patient achieve her goals