Nursing Diagnosis

Ineffective tissue perfusion (peripheral) related to anemia as manifested by pale nail beds,
cold clammy skin in the upper extremities and capillary refill of 3-4 seconds

Nursing Inference

During pregnancy the mother tries to increase blood volume to supply both her body and
the baby with this, the plasma begins to expand earlier and the volume is three times greater than
red blood cell mass. The disproportion of these volumes causes dilution of the red blood cell,
thus lowering the hemoglobin and hematocrit of the pregnant woman and would results to a
phenomenon called physiologic anemia of pregnancy hence, ineffective tissue perfusion.

Nursing Goal

After 30 minutes to 1 hour of rendering proper nursing interventions the client’s tissue
perfusion will be improved as would be manifested by pinkish nail beds, capillary refill of 0-2
seconds.

Nursing Interventions

Nursing Interventions Rationale

 Administer FeSO4 as ordered Elevates the serum iron concentration
which then helps to form High or
trapped in the reticuloendothelial cells
for storage and eventual conversion to a
usable form of iron
 Instruct client to drink fruit juice together Vitamin C enhances iron absorption.
with FeSO4
 Encourage client to increase food intake of Green leafy vegetable and liver contains
green leafy vegetables and liver. iron which could help in increasing iron
level of the client.
 Promote active/passive ROM exercises. Exercise prevents venous stasis and
further circulatory compromise.
 Encourage patient to walk with support hose Exercise helps increase venous return
on and perform toe up and point flex
exercises.
 Provide quiet and restful environment. It conserves energy/lowers tissue oxygen
demand
Nursing Evaluation

After 30 minutes to 1 hour of rendering proper nursing interventions the client’s tissue
perfusion was improved as manifested by pinkish nail beds, capillary refill of 0-2 seconds and
diminished edema.

Nursing Diagnosis

Fluid volume excess related to decreased oncotic pressure secondary to plasma protein
loss as manifested by grade 1 bipedal edema, pitting and cold clammy skin on both lower
extremities

Nursing Inference

Due to the vasoconstriction that happens in preeclampsia, decrease blood supply to vital
organs including the kidney occurs. There will be escape of large molecules including protein
due to the increase in molecular permeability. Furthermore, there will be the decrease in oncotic
pressure causing fluid shifting from intravascular to interstitial spaces hence, fluid volume
deficit.

Nursing Goal

After 2-3 days of rendering proper nursing interventions, the client would be able to
decrease edema as would be manifested by mild, non-pitting edema.

Nursing Interventions

Nursing Interventions Rationale

 Administer Furosemide as ordered Furosemide inhibits the reabsorption of sodium
and chloride from the loop of henle and distal
renal tubule thus promoting excretion of excess
fluid in the body
 Monitor vital signs especially cardiac Furosemide can cause hypokalemia and
rate and blood pressure decrease blood volume hence hypotension.
 Instruct client to adhere to low salt, low Having a low salt diet helps preventing further
fat diet water retention because salt enhances water
retention.
 Monitor client’s weight daily same Sudden weight gain could be indicative of
time, same weighing scale water retention
 Promote early ambulation To reduce tissue pressure and risk of skin
 breakdown

Nursing Evaluation

After 3 days of rendering proper nursing the client was able to decrease edema as
manifested by mild edema on lower extremities, non-pitting

Nursing Diagnosis

Impaired tissue integrity related to surgical incision as manifested by tenderness, redness,

swelling on the site.

Nursing Inference

Caesarean Section is the delivery of a baby through a surgical incision in a woman’s

abdomen and uterus. As such, it includes the disruption of the tissues near the incision site,
hence, impaired tissue integrity.

Nursing Goal

After 1-2 hours of effective nursing intervention, the client will be able to display
progressive improvement in wound healing as would be manifested by minimized tenderness,
redness and swelling on the incision site.

Nursing Interventions

Intervention Rationale

1. Teach the client with proper wound
care such as to:
 Wash hands before and after wound
handling
 Keep the are clean and dry
 Clean incision site with betadine
The body has the ability to regenerate tissue
injuries but with improper wound care, wound
healing can be delayed and infection can
occur.
 2. Tell patient to avoid rubbing and To prevent further injury and delayed healing
scratching the surgical incision

3. Encourage to eat foods rich in protein Protein is essential in tissue healing

4. Encourage to eat Vitamin C rich foods To boost the immune system and helps in
fighting infection.

5. Avoid strenuous activities Strenuous activities can cause abdominal

muscle contraction hence stretching the
incision site.

6. Administer antibiotics as ordered Cefuroxime inhibits cell wall synthesis

(Cefuroxime) and encourage to strictly causing bactericidal effect preventing
comply with prescribed medications infection and adhering strictly to prescribed
medication prevents drug resistance.

Nursing Evaluation

After 2 hours of effective nursing interventions, the client was able to display progressive
improvement in wound healing as manifested by minimized tenderness, redness and swelling on
the incision site.

Nursing Diagnosis

Acute pain related to tissue injury (cesarean) as manifested by grimacing face, guarding

behavior and a pain scale of 5/10.

Nursing Inference:
 When body tissues are injured or traumatize, chemical mediators are released. One of

these is histamine. Histamine increases capillary permeability. The increased in capillary

permeability and increased pressure of the blood flowing through dilated blood vessels enhance

the leakage of fluid from intravascular to interstitial spaces compressing the nerve endings, hence

pain is felt.

Nursing Goal:

After 30-60 minutes of rendering proper nursing interventions, the pain felt by the client

will be lessened as would be manifested by absence of grimacing face, lesser guarding behavior

and a pain scale of 1-3/10

Nursing Interventions

Nursing Interventions Rationale

1. Administer analgesics as ordered:
 Ketorolac  Ketorolac inhibits prostaglandin
synthesis by competitive blocking of
the enzyme cyclooxygenase
 Mefenamic Acid  Mefenamic acid inhibits the synthesis
of prostaglandin which is a pain
mediator.
 Paracetamol  Inhibits CNS prostaglandin synthesis
which is a pain mediator.
2. Encourage client to eat foods rich in protein Protein is essential for immune system and for
the repair of tissues
3. Encourage client to eat foods rich in Vit. C To boost the immune system and prevent
infection.
4. Instruct client to clean wound site with To prevent infection.
betadine.
5. Instruct client on the different diversional To divert attention and alleviate pain.
activities such as listening to music, talking
with husband, surfing the net.

Nursing Evaluation
 After 30-60 minutes of rendering proper nursing interventions, the pain felt by the client
was lessened as manifested by absence of grimacing face, lesser guarding behavior and a pain
scale of 3/10

Nursing Diagnosis

Risk for infection related to surgical incision

Nursing Inference

The client underwent “E” LTCS which involves incision in the abdomen. A break in the

skin integrity enhances entrance of microorganisms, hence risk for infection.

Nursing Goal

After 30-60 mins days of nursing intervention the client will be able to identify

interventions to prevent infection

Nursing Intervention

Nursing Interventions Rationale

1. Administer Cefuroxime as ordered This drug causes bactericidal effect by
inhibiting bacterial cell wall synthesis
2. Advise client to increase food intake rich in Protein enhances tissue repair
protein
3. Encourage client to eat foods rich in Vi. C. Vitamin C boosts the immune system which
helps in fighting infection.
4. Instruct client to clean surgical wound with To prevent infection.
soap, water and betadine.
5. Instruct client to keep wound site dry and To prevent harboring of microorganisms which
change dressings everyday. can cause infection.

Nursing Evaluation

After 30-60 mins of rendering proper nursing interventions, the client was able to identify
interventions that could prevent infection.