Nursing Background INFERENCE Goals and Objectives Interventions Rationale Evaluation

Diagnosis Study
Impaired Skin is the GOAL:
Skin/Tissue body’s first Emergency After 3 days of Goal met as
Integrity line of CS nursing interventions, evidenced by
related to defense the patient will be the patient has
mechanical against able to display timely able to display
trauma of foreign healing of skin timely healing
surgical materials Abdominal lesions/ wounds of skin lesions/
removal of skin that can be incision and without complication. wounds
and considered as Uterine without
subcutaneous injuring incision OBJECTIVES: Independent complication.
tissue agents. Once After 8 hours of
Establish rapport To gain trust
secondary to the skin is nursing interventions,
with the client
Cesarean disrupted, the patient will be
section this will put a Alterations able to:
person at risk of the Skin  Participate in Perform bedside
care To enhance
Assessment since it may prevention patient’s self
Subjective: become a measures and esteem and to
“Mayda ak good medium treatment provide comfort
samad kay gin for bacterial program to the patient
Cesarean ak growth.  Maintain
paganak,” Cesarean physical well-
verbalized by section, like Inspect skin on daily
being.
basis and obseve for To determine
the client. any other  Ability to
Objective: surgical changes and unusual ties and
manage
Destruction of procedures, unusualities report it to
situation.
skin layers includes physician for
Desruption of invasion of prompt
tissue layers. the inside treatment.
(+)Redness on body, Keep the area clean,
the incision specifically carefully dress
This will assist
site. the skin and wound, support
(+)Swelling on subcutaneous incison, prevent body’s natural
infection process of repair
the incision site area.
(NANDA 9th Encourage client to
edition.pp demonstrate good
461-465) skin hygiene, e.g., Maintaining
wash thoroughly clean, dry skin
(Med- and pat dry provides a
Surgical carefully after barrier to
Nursing, teaching.
infection. Patting
Black and
Hawks 8th skin dry instead
Edition pp of rubbing
952-954) reduces risk of
dermal trauma
DEPENDENT to fragile skin
Medication such as
antibiotics To prevent post
operative wound
complication
COLLABORATIVE
Provide optimum
nutrition such as To provide a
increased protein positive nitrogen
intake. balance to aid in
healing.

(NANDA 9th
edition pp 461-
465)
(Med-Surgical
Nursing, Black
and Hawks 8th
Edition pp 952-
954)
 Nursing Background INFERENCE Goals and Objectives Interventions Rationale Evaluation
Diagnosis Study
Acute pain Pain is Emergency GOAL:
related to defined as CS At the end of my Goal met as
abdominal unpleasant nursing intervention evidenced
of 8 hours duty, the by the
incision sensory and
Abdominal patient has
secondary emotional patient will be able to
and uterine able to
to surgery. experience incision report pain is relieved manage
arising from or controlled. pain relieve
Subjective actual or and
cues: Tissue OBJECTIVES: Independent controlled
potential
“Masakit pa trauma By the of 1hour of my To easily gain from 4to 6
tissue nursing intervention, Establish rapport
an tinahian cooperation form the to 2-3 on
damage or the client will: to the patient
han han ak patient the pain
described in rating scale.
tiyan nan terms of such Prostaglandin  Report pain To have baseline data
nakukurian damage. intensity from Monitor Vital
release+ and for comparison for
ak pagkiwa” (International Uterine 4 to 6 will signs future data
as Association Contraction+ decrease at 2
verbalized for the Study Loss of to 3 from 0 to To enhance patient’s
by the Anesthetic Perform bedside self esteem and to
of Pain); 10 pain scale.
patient. Effect care provide comfort to the
 Participate in patient
Objective demonstrating
cues: (Nurse’s techniques to Observe and By getting the following
Sensation of relieve pain document information, we are
Pocket Guide)
Temp: Pain location, severity asssitting in
38.4 °C  Have ability to and character of differentiating cause of
PR: 88 manage pain. pain and providing
bpm situation. information about
RR: 24 Elevated Vital disease
cpm Signs progression/resolution
BP: , development of
130/90 complications and
effective interventions.
 mm Hg
Rated Promote bedrest, Bedrest in low-fowler’s
pain as allowing patient to posiiton reduces
4 to 6 assume position of intraabdominal
out of 0 comfort pressure.
to 10
pain Control
scale. environment Cool surrounding aids
Pain temperature in minimizing dermal
increase discomfort.
s when Employ non
moves pharmacologic
vigorou pain distraction To prevent dependecy
sly such as: on medication for pain
Incision Music therapy,
site: Imagery,etc
Wound:
dry, no DEPENDENT
discharges Medication such Relieves pain
as NSAID’s immediately.
noted

Dressing
(NANDA 9th edition pp
and plaster
461-465)
were clean
and fully
covered the
incision site

No foul
odor noted
on the site.