Name of Patient : Mrs Christine Sanchez Age: 24 yrs old

IMPRESSION: PUFT Physician: Dr. Josefina Ebao

I. Physiologic Deficit Measures to:

A case of a 24 years old
care
female patient GiPo, post-partum
mother Mrs. Christine Sanchez
from Talisay City. Admitted for
the first time in Cebu Doctor’s
Hospital due to uterine contra-
ctions. On March 08, 2010.
She gave birth to a
healthy baby boy on March 09,
2010 @ 6:15 am.
A. impaired skin integrity 1. Promote wound healing
Cues:-presence of a median 1.1 keep the area clean and dry
Episiotomy. 1.2 encourage to verbalize feeling
- second degree laceration
90-95% 1.3 teach proper way of perineal
resolution of
of the perineum physiologic 1.4 encourage early ambulation
- “dugay lagi nahuman and 1.5 instruct mother to be exposed in
ug tahi Doc.” psychologic Perilite lamp.
problem. 1.6 provide hot bath
1.7 teach client about optimum nutrition
and increased protein intake.
1.8 administer pain reliever as prescribed.
II. Physiologic Deficit 2. Pomote fluid intake
B. Fluid volume deficit 2.1 provide oral case.
Cues: - dry skins 2.2 note client’s preference about fluids
- pallor and food or high fluid content.
- clammy hands I. Impaired Skin 2.3 establish a 24hr fluid replacement
- client was drinking water integrity r/t 2nd needs to be used
while she was interviewed degree laceration 2.4 administer antimetrics and antidiarhea
2* episiotomy as prescribed
“Mapuno ug dugo akong diaper” II. Fluid volume deficit 2.5 assist in administering oxytocin through
r/t median episiotomy 16 infusion.
III. Risk for infection r/t 2.6 anticipate clients needs at all times.
Median episitomy

III. Physiologic Deficit 3. prevent complications

C. Risk for infection 3.1 stress proper hardworking
Cues: -presence of a 3.2 provide perineal care
medianepisiotomy 3.3 promote perineal self-care
- diaper fully 3.4 instruct mother to be exposed on perilite
Soaked with lamp
blood 3.5 emphasize necessity of taking antibiotics
inform to report immediate signs of
infan.
administers antibiotics as pescribed.

Actual state of cues Ng.Dx Ng. Actions Desire

Patient’s Condition Objectives: Goal: Outcome
After 8 hrs of studentnurse- client After 2 days of
Interaction, the client will be able to: studentnurse- client inter-
1. participate in developing techniques action, the client will be
For wound healing able to attain optimum
2. maintain a fluid volume of a level of functioning
Functional level as evidenced
By warm, non- clammy skin.
3. prevent infections