Name of Patient: Mrs. Blancia, Via M.

Chief complaint: Pain Tremedal weeks

Age: 31 Sex: Female

Date: 04/14/09 Physician: Dr. Asucnion Diagnosis: Pregnancy Uterine, 37

Brunswick Lens Model 1.Pain - first day post CS = low segment transverse incision - sleep disturbance - expressive behavior (irritability) - narrowed focus - grimace or facial mask - PR: 84 beats per min. - RR:17 breaths per min. - BP: 110/70 - The patient rated pain as 8-9 / 10. She said that it occurs all the time at the lower abdomen. It will last for about 30 sec. to a

Measures to: I. relieve pain: 1. explain the cause of pain 2. monitor vital signs 3. assess pain scale and accept description of pain 4. provide rest periods to facilitate comfort, sleep and relaxation 5. provide comfort measures (such as touch, repositioning, use of heat / cold packs), quiet environment and calm activities. 6. teach or encourage relaxation techniques such as focused breathing, imaging, music therapy

A case of a 31 year old female patient that had a repeated low segment transverse cesarean section with ilateral tubal ligation (modified parkland) with physiologic complaints of

2. Constipation - unable to defecate two days before admission - 2 days post CS - 0-2 bowel sounds per min. - inactivity (lack of exercise) - weak abdominal muscle - nothing per orem for 8 hours after surgery - after 8 hours, clear liquid diet with only 18 cc - eats foodinfection 3. Risk for high in protein and low in fiber - post cesarean - presence of foley catetheter bag - low segment transverse insicion is covered with dressing - increased white blood cell count on the 2nd day of surgery - WBC = 16.10 103/uL If my dressing is removed, will the wound be prone to infection? as verbalized by the patient Actual State of Clients Condition Cues

II. establish normal pattern of bowel functioning: Altered comfort: 1. assess the color, consistency, amount and lower abdominal pain frequency of stool related to incision 2. encourage a diet high in fiber from cesarean 3. promote adequate fluid intake section 4. encourage activity or exercise within limits of individual ability Altered elimination 5. provide a routinely scheduled time for pattern: constipation defecation related to decreased 6. administer enema or suppository, Dulcolax, one motility and III. remain free of infection: decreased oral intake 1. monitor vital signs 2. assess nutritional status, including history of Risk for infection weight loss related to presence 3. note any signs and symptoms of sepsis: fever, of incision site chills, and diaphoresis 4. provide regular catheter, perinear and/or wound care 5. perform proper hand washing by all caregivers 6. maintain sterile technique for all invasive procedures (e.g. changing IVF, FBC) 7. administer antibiotics, Cefuroxime (Zegen) 500 Nursing Diagnosis Nursing Interventions Nursing Objectives Nursing Goal After 8 hours of student-nure-patientinteraction, the patient

80% resolution of physical and psychological problems.

Outcome

will be able to: care,

After 1 week of holistic nursing

32

1. verbalize a decreased level of pain as evidenced by the patient will be able to achieve decreased pain scale from 8-9 / 10 to 5/10 optimum level of functioning. 2. remain free of infection as evidenced by normal temperature 3. eliminate soft, formed stool at a frequency perceived as normal by the patient

28 33