NURSING CARE PLAN

Nursing Diagnosis # 1: Deficient fluid volume related to blood loss during surgery as
evidenced by 800 mL blood loss and 2 pad count change while on recovery room due to
vaginal bleeding.
Goal: To prevent hypovolemia and dehydration
Expected Outcome: At the end of nursing shift, the patient will have:
• Urine output greater than 30 mL/ hr. (Clinical Outcome)
• Normotensive blood pressure (90-120/ 60-80 mmHg). (Clinical
Outcome)
• Heart rate less than 100 beats/ minutes (80- 100 bpm). (Clinical
Outcome)
• Consistency of weight. (Clinical Outcome)
• Normal skin turgor. (Clinical Outcome)
Intervention Evaluation
PROMOTIVE

1. Monitor and document vital signs. - Vital signs:

Temperature: 36˚ C
Rationale: Pulse rate: 79 bpm
• Sinus tachycardia may occur Respiratory rate: 18bpm
with hypovolemia to maintain Blood pressure: 110/70 mm Hg
an effective cardiac output. Pain scale: 0/10
Usually the pulse is weak and At 1015H
may be irregular if electrolyte Blood pressure: 89/ 53 mm Hg
imbalance also occurs. At 1310 H
Hypotension is evident in 100/80 mm Hg
hypovolemia.
- (+) pale and smooth skin
2. Monitor blood pressure for orthostatic - Capillary refill of 4- 5 seconds
changes (from patient lying supine to - 2 pad count for 3 hours
high- Fowler’s). - (+) of excessive vaginal bleeding
- Estimated 800 mL blood loss
Rationale:
• Postural hypotension is a - Partially met.
common manifestation in fluid
loss. Note the following
orthostatic hypotension
significance:
a. Greater than 10 mmHg
drop: circulating blood
volume is decreased by 20
%
b. Greater than 20 to 30 mmHg
drop: circulating blood
volume is decreased by 40
 %

3. Assess skin turgor and mucous

membranes for signs of dehydration.

Rationale:
• The skin in older patients loses
its elasticity; therefore skin
turgor should be assessed over
the sternum or on the inner
thighs. Longitudinal furrows
may be noted along the tongue.

4. Monitor temperature.

Rationale:
• Febrile states decrease body
fluids through perspiration and
increased respiration.

5. Observe for the perineal pad. Document

pad count.

Rationale:
• To assess vaginal discharge and
monitor blood loss.

6. Teach the causes of fluid losses

Rationale:
• Information is key to managing
the problem.
 NURSING CARE PLAN

Nursing Diagnosis # 2: Risk for ineffective peripheral tissue perfusion related to blood loss.
Goal: To improve blood circulation and tissue perfusion.
Expected Outcome: At the end of nursing shift, the patient will
• Maintain fluid balance, with intake equal to output
• Maintain urine specific gravity within normal parameters
• Maintain respiratory rat within 5 breaths/ minute of baseline
• Have no rhonchi and crackles
• Exhibit improved circulation
• Communicate understanding of medical regimen, diet, medication and
activity restriction
Intervention Evaluation

1. Monitor patient’s heart rate and - Vital signs:

rhythm, CVP, and blood pressure every
hour until stable; record and report any
changes above or below established
limits. Monitor skin color and
temperature every 2 hours.
Rationale:
• Decreased heart rate, CVP, and
blood pressure can indicate
hypovolemia, which leads to
decreased tissue perfusion.
Blanched and mottled, cool skin
indicates decreased tissue
perfusion.
Temperature: 36˚ C
Pulse rate: 79 bpm
Respiratory rate: 18bpm
Blood pressure: 110/70 mm Hg
Pain scale: 0/10
At 1015H
Blood pressure: 89/ 53 mm Hg
At 1310 H
100/80 mm Hg
- (+) pale and smooth skin
- Capillary refill of 4- 5 seconds
- 2 pad count for 3 hours
- (+) of excessive vaginal bleeding

2. Monitor respiratory rate and depth Partially met.

every hour until stable. Record and
report changes outside established
limits.

Rationale:
• Increased respiratory rate is a
compensatory mechanism of
tissue hypoxia that can result
from decreased tissue perfusion.

3. Measure and record urine output every

hour until output exceeds 30 mL/ hour.
 Rationale:
• If patient has no history of renal
disease, urine output is a good
indicator of tissue perfusion.
Decreased or absent urine
output usually indicates poor
renal perfusion.

4. Keep patient warm, but don’t overheat.

Rationale:
• Warmth aids vasodilation,
which improves tissue
perfusion.

5. Elevate patient’s lower extremities

Rationale:
• To increase arterial blood
supply and improve tissue
perfusion.

6. Change patient’s position regularly,

follow turning scheduled, inspect his
skin every shift, and record and report
any potential areas of breakdown.

Rationale:
• These measures help prevent
decreased tissue perfusion and
reduce the risk of skin
breakdown.

7. Educate patient in the medical regimen

Rationale:
• To allow patient to take an
active role in health
maintenance.
 NURSING CARE PLAN

Nursing Diagnosis # 3: Risk for infection related to altered primary defenses secondary to
surgical incision.
Goal: To prevent further infection.
Expected Outcome: At the end of nursing shift, the patient:
• Have stable vital signs. (Clinical Outcome)
• Results of laboratory studies won’t indicate infection. (Clinical Outcome)
• Respiratory secretions and urine won’t show evidence of infection.
(Clinical Outcome)
• Abdominal incision site will remain free from infection. (Clinical
Outcome)
• I. V. sites won’t become inflamed. (Clinical Outcome)
• Maintain good personal hygiene. (Clinical Outcome)
• Remain free from signs and symptoms of infection. (Clinical Outcome)
Intervention Evaluation

1. After delivery, monitor vital signs - Vital signs:

every 15 minutes for 1 hour, then every
4 hours for 24 hours, then every shift
until discharge. Report abnormal
readings.
Rationale:
• Elevated temperature, pulse or
respiratory rates, or blood
pressure may indicate infection.
A temperature greater than 38˚
C on two consecutive readings
after the first 24 hours post
delivery may indicate puerperal
sepsis, urinary tract infection,
endometritis, mastitis, or other Goal met.
infection.
Temperature: 36˚ C
Pulse rate: 79 bpm
Respiratory rate: 18bpm
Blood pressure: 110/70 mm Hg
Pain scale: 0/10
At 1015H
Blood pressure: 89/ 53 mm Hg
At 1310 H
100/80 mm Hg
- (+) pale and smooth skin
- (-) redness, discharge and swelling of
abdominal site
- (-) inflammation of I. V. site

2. Instruct the patient in proper hygiene,

such as use of sitz bath and perineal
irrigation bottle, hand washing, and
breast care

Rationale:
• To reduce the risk of infection.

3. Use sterile technique when performing

 invasive procedures, such as urinary
catheterization.

Rationale:
• To minimize the risk of
introducing pathogens into the
body.

4. Assess the I. V. site for 2 hours, noting

the presence of redness or warmth.

Rationale:
• These measures keep pathogens
from entering the body

5. Encourage to intake nutritional foods

after NPO.

Rationale:
• A diet high in protein, iron and
vitamin C helps promote
healing.

6. Assess the patient for generalized signs

and symptoms of infection (pallor,
fatigue, malaise, anorexia and chills)
every shift, and instruct her to report
danger sings immediately. These
include foul- smelling lochia, calf
tenderness, elevated temperature,
dysuria, marked abdominal tenderness,
and tender, reddened breasts and feel
warm to touch.

Rationale:
• Prompt detection of infection
helps minimize complications.

NURSING CARE PLAN

Nursing Diagnosis # 4: Constipation related to effects of abdominal surgery and anesthesia
as evidenced by presence of abdominal incision and administration of spinal anesthesia.
Goal: To improve and maintain the normal bowel pattern.
Expected Outcome: At the end of nursing shift, the patient:
• Will passes soft, formed stool at a frequency perceived as normal by the
patient. (Clinical Outcome)
• Verbalizes the measures that will prevent recurrence of constipation.
(Clinical Outcome)
Intervention Evaluation

1. Assess usual pattern of elimination; - Vital signs:

compare with present pattern. Temperature: 36˚ C
Pulse rate: 79 bpm
Rationale: Respiratory rate: 18bpm
• Normal frequency of passing Blood pressure: 110/70 mm Hg
stool varies from twice daily to Pain scale: 0/10
once every third or fourth day. At 1015H
It is important to ascertain what Blood pressure: 89/ 53 mm Hg
is “normal” for each individual. At 1310 H
100/80 mm Hg
After the NPO: - NPO
- (-) bowel movement
2. Encourage daily fluid intake of 2000 to - Under spinal anesthesia lasts for 24
3000 mL/ day, if not contraindicated hours.
medically.
Partially met.
Rationale:
• Patients, especially older
patients, may have
cardiovascular limitations that
require that less fluid be taken.

3. Encourage increased fiber in diet; a

minimum of 20 g of dietary fiber per
day is recommended.

Rationale:
• Fiber passes through the
intestine essentially unchanged.
When it reached the colon, it
absorbs water and forms a gel,
which adds bulk to the stool and
makes defection easier.

4. Encourage the patient to consume

prunes, prune juice, cold cereal and
 bean products.

Rationale:
• These are natural cathartics
because of their high- fiber
content.

5. Health teaches about the importance

regular exercise.

Rationale:
• This explains that ambulation
and/ or abdominal exercises
strengthen abdominal muscles
that facilitate defecation.

6. Suggest minimizing rectal discomfort

use warm sitz bath.

Rationale:
• The warmth of the water relaxes
muscles before defecation
attempts.

7. Offer a warmed bedpan to bedridden

patients; assist the patient to assume a
high- Fowler’s position with knees
flexed.

Rationale:
• The position best uses gravity
and allows for effective
Valsalva maneuver.

NURSING CARE PLAN

Nursing Diagnosis # 5: Impaired skin integrity related to abdominal incision as evidenced
destruction of skin surface.
Goal: To prevent infection and permanent damage of the skin surface.
Expected Outcome: At the end of nursing shift, the patient will:
• Demonstrate understanding of self care activities. (Clinical Outcome)
• Perform skin care routine. (Clinical Outcome)
• Identify possible danger signs and report them immediately to physician.
(Clinical Outcome)
• Regain skin integrity. (Clinical Outcome)
• Express feelings about possible change in body image. (Clinical Outcome)
• Patient’s abdominal incision will heal without infection. (Clinical
Outcome)
Intervention Evaluation

1. Inspect the incision every shift using - Vital signs:

the REEDA (redness, edema, Temperature: 36˚ C
ecchymosis, discharge and Pulse rate: 79 bpm
approximation) method. Document Respiratory rate: 18bpm
findings. Blood pressure: 110/70 mm Hg
Pain scale: 0/10
Rationale: At 1015H
• Frequent assessment can detect Blood pressure: 89/ 53 mm Hg
signs and symptoms of possible At 1310 H
infection. 100/80 mm Hg

2. Perform the prescribed treatment - (+) pale and smooth skin

regimen. Monitor progress and report - (-) redness, discharge and swelling of
favorable and adverse responses. abdominal site
- (-) inflammation of I. V. site
Rationale: Goal Met.
• Periodic cleaning decreases
bacterial concentrations, thus
aiding the healing process.
Monitoring response to
treatment can help identify a
possible need for alternative
interventions.

3. Provide a splinting pillow for the

patient with an abdominal incision.

Rationale:
• Splinting provides support to
the area, minimizing discomfort
and encouraging the patient to
move and cough.
4. Help the patient assume a comfortable
position.

Rationale:
• To minimize the incidence of
pain- induced immobility.

5. Inform the patient of the purpose of self

care practices.

Rationale:
• To increase compliance.

6. Instruct the patient in the possible

danger signs and symptoms should be
reported to the physician immediately.
These include:
- Temperature of above 38˚ C on two
consecutive readings
- Incisional drainage
- Increased discomfort at the incision
site
- Reddened or warm skin
surrounding the incision site

Rationale:
• Prompt reporting of danger
signs and symptoms may help
prevent major complications.