8/14/2019 OB Nursing Care Plan Patient Tahbso CS Rodriguez
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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE
EVALUATION
SUBJECTIVE
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OBJECTIVE
oTemperature36.5 C
o PR: 69bpmo RR: 20cpmo BP: 110/70
mmHgo Rated pain 8
out of 10o Impaired
physicalmobility
o Painincreaseswhen movesvigorously
o Guardingbehavior
o alert,conscious,coherent
o With dry andintactsurgicaldressing onhypogastric
area of theabdomen
Acute painsecondary tosurgicaloperation
CS andTAHBSO
Abdominalincision and
Uterine incision
Alterations ofthe Skin
After 1 day ofnursinginterventions,patients painwill diminishand
performactivities likesitting,standing andwalking.
Independent:oIdentify specific
activity limitations.oRecommend
planned orprogressiveexercise.
o Scheduleadequate restperiods.
oReview importanceof nutritious dietsand adequate
fluidintake.
oReposition asindicated.
oProvide additionalcomfort measureslike back rub.
Dependento Medication such
as antibiotics andanalgesics
Collaborativeo High-fiber diet
oPrevents undue strainon operative site.
oPromotes return ofnormal function andenhances feelings
ofgeneral wellbeing.
oPrevents fatigue andconserves energy forhealing.
oProvides elementsnecessary for tissueregeneration or healingand
to avoidhypovolemic shock
oMay relieve pain andenhance circulation.
oImproves circulation,reduces muscle tensionand anxiety
associatedwith pain
oTo prevent post-operative woundcomplication andrelieve pain
oTo avoid constipation
After 1 dayof nursinginterventions, the patientpain wasrelieved
orcontrolledand patientis able toambulate.
