ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME

Subjective: Acute pain STG: Independent: Goal met.

“Sobrang sakit po related to After 4hrs of After 4hrs of
ng tahi lalo na po disruption of nursing - Established -To have a nursing
pag gumagalaw skin and intervention, rapport. good nurse- intervention,
ako,” as tissue patient will client the patient
verbalized by the secondary to verbalize relationship verbalized
patient. cesarean decrease pain
section. intensity of - Monitored vital -To establish decreased
Objective: pain from signs. a baseline from a scale
-Pain scale= 8/10 8/10 to data of 8/10 – 3/20
-Teary eyed 3/10. as evidenced
-(+) guarding - Assessed -To establish by
behavior quality, baseline data (-) facial
-(+) facial characteristics, for grimace
grimace severity of comparison (-) guarding
-Irritable pain. in making behavior.
-Skin warm to evaluation Frequent
touch and to small talks
- V/S taken as assess for with
follows: possible significant
BP= 110/80 internal others
PR= 99 bleeding.
RR= 20
T= 37.2 - Provided -Calm
comfortable environment
environment – helps to
changed bed decrease the
linens and anxiety of the
turned on the patient and
fan. promote
likelihood of
decreasing
pain.

- Instructed to - To check for

put pillow on diastasis recti
the abdomen and protect
when coughing the area of
or moving. the incision
to improve
comfort. And
to initiate
nonstressful
muscle-
setting
techniques
and progress
as tolerated,
based on the
 degree of
separation.

- Instructed - For
patient to do pulmonary
deep breathing ventilation,
and coughing especially
exercise. when
exercising,
and to relieve
stress and
promote
relaxation.

- Provided - To promote
diversionary circulation,
activities. prevent
Initiate ankle venous
pumping, stasis,
active lower prevent
extremity ROM, pressure on
and walking the operative
site.
Collaborative:
- Administer -Relieves
analgesic as pain felt by
per doctor’s the patient
order.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for STG: Independent Goal met
“Pumutok na po infection After 4 hours -Monitor vital -To establish After 4 hours
panubigan ko related to post of nursing signs a baseline of nursing
pero 2days pa po operative intervention, data intervention,
bago ako na cs,” surgical patient will -Inspect dressing patient was
as verbalized by procedure as be able to and perform -Moist from expected to be
the patient. evidenced by understand wound care drainage can free of
incision site causative be a source of infection, as
factors, - Monitor white infection evidenced by
Objective: identify signs blood count (WB normal vital
- wound dressing of infection - Rising WBC signs and
hasn’t been and report indicates absence of
change. them to body’s efforts purulent
health care to combat drainage from
- Redness in the provider pathogens; wounds,
incision site. accordingly. normal incisions, and
-V/S taken as - Monitor Elevated values: 4000 tubes.
follows: LTG: temperature, to 11,000 mm3
T: 37.3 After 2-3 Redness, Goal met
P: 100 days of swelling, -these are After 2-3 days
R: 20 nursing increased pain, or signs of of nursing
BP: 110/80 intervention, purulent drainage infection intervention,
patient will at incisions patient has
demonstrate demonstrated
proper hand - Wash hands and -Friction and proper hand
washing and teach other running water washing and
prevent caregivers to effectively prevent
infection wash hands remove infection
control before contact microorganis control
technique. with patient and ms from technique.
between hands.
procedures with Washing
patient. between
procedures
reduces the
risk of
transmitting
pathogens
from one area
of the body to
another

- Encourage fluid - Fluids

intake of 2000 ml promote
to 3000 ml of diluted urine
water per day and frequent
(unless emptying of
contraindicated). bladder;
reducing
stasis of urine,
in turn,
reduces risk
of bladder
infection or
urinary tract
infection
(UTI).

- Encourage - These
coughing and measures
deep breathing; reduce stasis
consider use of of secretions
incentive in the lungs
spirometer. and bronchial
tree. When
 stasis occurs,
pathogens
can cause
upper
respiratory
infections,
including
pneumonia.
Independent:
- Administer -Antibiotics
antibiotics have
bactericidal
effect that
combats
pathogens.
Drug Name Indication Mechanism of Adverse Reaction Nursing Patient Teaching
Action Consideration

Generic Name: Benadryl® Allergy Diphenhydramine General: Urticaria, *Assess for possible *Advised that this drug may cause
(diphenhydramine) Uses acts as an inverse drug rash, contraindications or drowsiness and has an additive effect
diphenhydramine agonist at the H1 anaphylactic shock, cautions. with alcohol.
• temporarily receptor, thereby photosensitivity,
relieves these * Assess the skin *Tell the patient
reversing effects of excessive
symptoms due color, texture, and
Brand Name: to hay fever or histamine on perspiration, chills, The side effects may occur: Dizziness,
capillaries, reducing dryness of mouth, lesions to monitor
other upper sedation, drowsiness; epigastric
Benadryl for anticholinergic
respiratory allergic reaction nose, and throat distress, diarrhea, or constipation; dry
allergies: symptoms. Lastly, effects or allergy.
Cardiovascular mouth (use frequent mouth care, suck
o runny diphenhydramine
nose * Evaluate sugarless lozenges); thickening of
Dosage: acts as an System:
o sneezing Hypotension, orientation, affect, bronchial secretions, dryness of nasal
o itchy,
intracellular sodium and reflexes to mucosa (use a humidifier).
25 mg to 50 mg headache,
watery channel blocker, monitor for changes
resulting in local palpitations,
eyes due to CNS effects.
o itching anesthetic tachycardia,
Route: of the extrasystoles * Assess respirations *Instruct Patient to Report difficulty
properties
nose or and adventitious of breathing, hallucinations, tremors,
Parenteral (IM) throat Hematologic System: loss of coordination, unusual bleeding
Hemolytic anemia, sounds to monitor
• temporarily or bruising, visual disturbances,
relieves these thrombocytopenia, drug effects.
irregular heartbeat.
symptoms due agranulocytosis
Frequency: * Evaluate renal and
to the common
cold: Nervous System: liver function tests
q6h o runny to monitor for
Sedation, sleepiness,
nose dizziness, disturbed factors that could
o sneezing affect the
coordination,
Timing: fatigue, confusion, metabolism or
restlessness,
1a-7a-1p-7p excitation, excretion of the
nervousness, tremor, drug.
(6 hourly after initial irritability, insomnia,
dose.) euphoria,
paresthesia, blurred
vision, diplopia,
Classification vertigo, tinnitus,
acute labyrinthitis,
Antihistamines
neuritis, convulsions

GI System: Epigastric
distress, anorexia,
nausea, vomiting,
diarrhea,
constipation

GU System: Urinary
frequency, difficult
urination, urinary
retention, early
menses

Respiratory System:
Thickening of
bronchial secretions,
tightness of chest or
throat and wheezing,
nasal stuffiness
 DOSAGE, ROUTE, INDICATION/ ACTION ADVERSE EFFECTS NURSING RESPONSIBILITIES
DRUG NAME CONTRAINDICATIONS
FREQUENCY

Paracetamol 200mg IM The preparation is - Should not be - In rare cases - If to be given as

indicated in diseases used in hypersensitivity analgesia, assess onset,
manifesting with pain hypersensitivity reactions, type, location, duration
and fever: headache, to the predominantly of pain.
toothache, mild and preparation skin allergy - Can be given without
moderate and in severe (itching and regards to meals.
postoperative and liver diseases. rash), may - Tablets can be crushed.
injury pain, high appear. Long- - Assess temperature
temperature, term treatment directly before and 1
infectious diseases, with high doses hour after giving
and chills (acute may cause a medication.
catarrhal toxic hepatitis - If respirations are
inflammations of the with following <12/min (<20/min in
upper respiratory initial children), withhold the
tract, flu, smallpox, symptoms: medication and contact
parotitis, etc.). nausea, the physician.
vomiting,
sweating, and
discomfort.
- Occasionally a
gastrointestinal
discomfort may
be seen.

Submitted by: KLARENZ NILO 4B2 JULY 6, 2022