NCP and Fdar.

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Assessment Nursing Scientific Planning Nursing Rationale Evaluation

Diagnosis Rationale Interventions

Subjective: Risk for Skin Susceptible Short term: •Raised side •To provide •Goal met, The
Integrity r/t to alteration rails safety patient will no
"Pag IVF via in epidermis After 4 longer show
hinahawakan ko cesarean and/ or hours of •Monitored •To provide any sign of
po ang tahi ko, section aeb dermis, nursing VS and baseline data facial grimace,
napaka sakit po Multiple which may interventio recorded temperature
niya at ang dry attempt and compromise ns, the (T,BP) and BP will
po sa surgical health. patient's return to
pakiramdam" as incision. skin will no •Performed •To alleviate normal, and
verbalized by the longer feel Tsb body’s pain scale from
patient dry, no temperature 7/10 decreased
presence and to prevent to 3/10.
Objective: of facial skin from
Grimace, drying
>VS taken as and from a
Follows: pain scale
T:37.8 of 7/10 to •Encouraged •To keep the
PR:90 bpm 5/10. to increased patient
RR:19 bpm fluid intake hydrated
BP:130/90 Long term:
•Encouraged •To prevent
>Grimace After a day bed rest fatigue
>Pain scale of of nursing
7/10 interventio •Instructed •To prevent
ns, the the patient to the wound to
patient will limit physical open
no longer movement
show any
facial •Instructed •To aid for the
Grimace, the pt to call pt as soon as
no for nurse as possible
complainin needed
g of
dryness
along the
sutor site
and will
verbalize
"hindi na
po sya
masakit".
Assessment Nursing Scientific Planning Nursing Rationale Evaluation
Diagnosis Rationale Interventions

Subjective: Risk for Susceptible Short term: •Established •To •Goal met,
Injury r/t IVF to physical Rapport established After the
"Medyo via cesarean damage due After 4 hours trust nursing
nahihirapan po section aeb to of nursing interventions
ako sa lagay deficient environment interventions, •Provided a •To keep the , the patient
ko, kasi hindi knowledge al conditions the patient calm pt will
ko po alam regarding interacting will no longer environment comfortable demonstrate
ang gagawin the with the panic and will on how to
ko"as procedure individual’s show •Initiated •To ensure properly aid
verbalized by and adaptive and eagerness to health effective herself, and
the patient treatment defensive know how to literacy communicati will no longer
needs. resources, do basic on between feel panic.
Objective: which may treatment for the
compromise her case. healthcare
>VS taken as health provider and
Follows: Long term: client
T:36.5
PR:105 bpm After a day •Promoted •To empower
RR:20 bpm the patient adherence to the pt to
BP:120/80 will treatment participate
demonstrate
>Restlessness on how to •Provided •To help
properly aid strategies for convey
herself, and teaching the teaching
will verbalize pt. effectively
that she will
no longer •Instructed •To aid for
panic next the pt. to call the
time. for a nurse pt.questions
when
needed
FOCUS Risk for Skin Integrity r/t IVF via cesarean section aeb Multiple attempt
and surgical incision.

DATA >Received patient lying on bed and awake.

>VS taken as Follows:


T:37.8
PR:90 bpm
RR:19 bpm
BP:130/90

>Grimace
>Pain scale of 7/10

ACTION •Raised side rails

•Monitored VS and recorded (T,BP)

•Performed Tsb

•Encouraged to increased fluid intake

•Encouraged bed rest

•Instructed the patient to limit physical movement

•Instructed the pt to call for nurse as needed

RESPONSE •The patient will no longer show any sign of facial grimace,
temperature and BP will return to normal, and pain scale from 7/10
decreased to 3/10.
FOCUS Risk for Injury r/t IVF via cesarean section aeb deficient knowledge
regarding the procedure and treatment needs.

DATA >Received patient lying on bed and awake.

>VS taken as Follows:


T:36.5
PR:105 bpm
RR:20 bpm
BP:120/80

>Restlessness

ACTION •Established Rapport

•Provided a calm environment

•Initiated
health literacy

•Promoted adherence to treatment

•Provided strategies for teaching the pt.

•Instructed the pt. to call for a nurse when needed

RESPONSE •The patient will demonstrate on how to properly aid herself, and will
no longer feel panic.

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