Nursing Care Plan
Nursing care plan
Name of client: Miss Ng Sex: F Date of assessment: 31/10/2014 Medical diagnosis: Caesarian section
Diagnostic statement: Impaired comfort related to tissue trauma and reflex muscle spasms secondary to surgery as evidenced by vomiting
Assessment
Nursing diagnosis
Goals & expected outcome
Nursing interventions
Rationales
Method of evaluation
Subjective data:
1. Patient reported of abdominal pain.
2. Elevated scoring of 8/10 of pain score
Objective data:
1. Restlessness
2. Facial grimacing
3. Fatique
Problem:
Impaired comfort
Etiology:
1. Related to decreased tissue trauma and reflex muscles spasms
Signs and symptoms:
1. Vomiting four times per hour
Goal:
The woman will verbalize reduced discomfort or will be able to use effective techniques to decrease perception of pain
Short term expected outcome:
Within 2 hours of nursing interventions, the woman will have improved control of abdominal pain as evidenced by:
1. States a decrease in rating of abdominal pain
2. Is able to rest, display reduced tension, and sleep comfortably with decrease worries.
3. Requires decrease analgesia such as panadol
1. Determine the nature, duration, and location of pain
2. Encourage the woman to continue using coping mechanisms learnt during prenatal classes. Use therapeutic touch to increase comfort.
3. Maintain a calm manner and environment
4. Facilitate taking care of the newborn.
1. Locating the site of pain helps identify complications that may be occurring. Assessing pain and contractions can help identify a prolonged contraction that can cause fetal hypoxia.
2. A feeling of loss of control can increase the perception of pain. Reduction of tension can promote comfort.
3. A calm manner calms the parents and reduces anxieties and tensions that elevate pain perception.
4. The newborn causes stress to its mother. Taking care of the newborn by staff ease the woman’s physical workout.
Short term goals:
Within 2 hours of nursing intervention, the patient had
Name of client: Miss Ng Sex: F Date of assessment: 31/10/2014 Medical diagnosis: Caesarian section
Diagnostic statement: Impaired comfort related to tissue trauma and reflex muscle spasms secondary to surgery as evidenced by vomiting
Assessment
Nursing diagnosis
Goals & expected outcome
Nursing interventions
Rationales
Method of evaluation
Subjective data:
1. Patient reported of abdominal pain.
2. Elevated scoring of 8/10 of pain score
Objective data:
1. Restlessness
2. Facial grimacing
3. Fatique
Problem:
Impaired comfort
Etiology:
1. Related to decreased tissue trauma and reflex muscles spasms
Signs and symptoms:
1. Vomiting four times per hour
Goal:
The woman will verbalize reduced discomfort or will be able to use effective techniques to decrease perception of pain
Short term expected outcome:
Within 2 hours of nursing interventions, the woman will have improved control of abdominal pain as evidenced by:
1. States a decrease in rating of abdominal pain
2. Is able to rest, display reduced tension, and sleep comfortably with decrease worries.
3. Requires decrease analgesia such as panadol
1. Determine the nature, duration, and location of pain
2. Encourage the woman to continue using coping mechanisms learnt during prenatal classes. Use therapeutic touch to increase comfort.
3. Maintain a calm manner and environment
4. Facilitate taking care of the newborn.
1. Locating the site of pain helps identify complications that may be occurring. Assessing pain and contractions can help identify a prolonged contraction that can cause fetal hypoxia.
2. A feeling of loss of control can increase the perception of pain. Reduction of tension can promote comfort.
3. A calm manner calms the parents and reduces anxieties and tensions that elevate pain perception.
4. The newborn causes stress to its mother. Taking care of the newborn by staff ease the woman’s physical workout.
Short term goals:
Within 2 hours of nursing intervention, the patient had