KAREN ELIZABETH B. VALDEZRLE 2

NURSING CARE PLAN

CUES AND CLUES NURSING DIAGNOSIS

ANALYSIS GOALS AND OBJECTIVES

IMPLEMENTATION RATIONALE EVALUATION

Subjective “masakit yung

sugat ko parang umuuga at nagsheshake yung body organs ko” as verbalized

Objective Underwent

LTCS 2 days

postpartum Pain over the

incision. Rated it 7 out of 10

Voids every 3 hours

T= 35.9 PR = 78 bpm RR= 18 BP= 110/70 With dry and

intact dressing on the area

Risk for infection related to surgical incision

The skin is considered as the first line of defense against any foreign organism. When surgical procedure like caesarean delivery impaired the skin, there is a possibility that microorganisms enter therefore may cause infection

After 4 hours of nursing intervention patient will be free of infection as manifested by timely wound healing and normal vital signs and will identify interventions to prevent and reduce risk of infection

Stress the importance of personal hygiene especially hand hygiene

Rendered bed bath with warm water

Change the bed linens regularly.

Advised to wear slippers when walking

Clean the wound and change the dressing as needed

Perform perineal care with warm water and mild soap at least once daily

Reduces risk of spreading the foreign organisms

To promote hygiene as well as pain relief

To prevent contamination

To avoid contaminating the linens when she return to bed

To promote healing of the incision and to reduce risk of infection

To promote hygiene and comfort and prevent

After 4 hours of nursing intervention patient was not infected as manifested in her vital signs which is within normal limits and reduced pain scale to 6 out of 10

KAREN ELIZABETH B. VALDEZRLE 2

NURSING CARE PLAN

Dressing has no binder

Minimal lochia rubra

Change peripad if soaked

Assess amount and character of lochia with each pad change

infection To prevent

infection and contamination of genitourinary area

To know if there's yellow discharges that indicates infection