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Name of Student: Arianne Kamille E.

Andes Section/Group Number: BSN IV 2 Group 8 ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION

Patients Name: Eufrocina Galang Diagnosis: Emergency CS with BTL OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME

S= O= The manifested: facial grimaces guarding behavior dry and intact incision site WBC 17,000 x cells/mm3 Pain sclae of 6/10 The patient - alteration vital signs signs of may in of 10^9

Impaired patient integrity layers

skin Caesarean Section is a Short Term: incisions through are Nursing

- Monitor and record vital - To establish baseline Short Term: data Note The patient will have an improved general - To identify underlying position of function and will maintain optimal nutrition and physical well-being Note changes in skin - To assess extant of involvement and injury Long Term: Inspect for surrounding - To assess extant of The erythema, involvement and injury To have wound determine without patient a healing will timely of any skin

r/t surgical procedure in After 4 hours of signs made a Interventions, the improved mobility of optimal color, texture, and turgor and well- -

disruption of skin which

womans abdomen and patient will have debilitation and reduces or causative factors uterus to deliver one or an more usually babies. It is position

performed function and will -

when a vaginal delivery maintain may put the baby's or nutrition mother's life or health physical at risk, although times it in being has recent upon

induration and ulcers

been also performed request for Long Term: childbirths that could After 54 days of the skin lesions otherwise have been Nursing natural. performance surgical incision In the interventions, the Instruct patient change and

- Note odor emitted from presence of infection or complications. complications on To determine

manifest:

of patient will have a proper wound dressing is healing of without cleaning

of presence of infection or wound complications

caesarean section, a timely

infection such as fever

done,

causing

an any - Encourage patient to - To promote tissue take foods rich in Vitamin repair C Encourage deep - To relieve discomfort - To enhance blood Encourage gradual circulation thus ambulation promoting tissue repair

alteration or a break in complications. the skin integrity. By which, the incision causes direct irritation to the nerve endings by chemical incision mediators such as released at the site of bradykinin, leading to different manifestations such impaired mobility. as pain, and physical discomfort,

breathing exercises