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POSTCS

The document describes a patient case involving a post-cesarean section with an expired baby. It details the patient's subjective complaints of pain, objective assessments, pain management plan, nursing interventions, and evaluation of outcomes.

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Lorenz Jude Cańete
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14 views3 pages

POSTCS

The document describes a patient case involving a post-cesarean section with an expired baby. It details the patient's subjective complaints of pain, objective assessments, pain management plan, nursing interventions, and evaluation of outcomes.

Uploaded by

Lorenz Jude Cańete
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
Download as pdf or txt
Download as pdf or txt
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Patient Name: Salipong, Quenzie Date: August 16, 2023

Patient Room No: 205


Case: Post-Cesarean Section (expired baby)
SOAPIE
SUBJECTIVE
• “Hapdos akong tahi ug nagsakit akong tuo nga abaga.” As verbalized by client.
• Reported pain with intensity of 7 on the standardized pain scale where 1 has the least pain and 10 has the severe pain.

OBJECTIVE • Received lying on bed, awake and responsive, w / IVF bottle #D5LR 1L + 20 units of oxytocin regulated at 30 gtts/min @ RMCV
infusing well at the level of 850 cc.
• Cold compression at surgical incision site, noted.
• Facial expression of pain / grimace
• Guarding / protective behavior
• Positioning to ease pain
• Irritability
• Discomfort
• with Foley Bag Catheter draining well to Uro Bag w yellowish color at 300 cc level.
• with initial vital signs as follows:
Temperature: 37.5°c
Pulse rate: 88 bpm
Respiratory rate: 20 cpm
Blood pressure: 110 /70 mmHg

ANALYSIS • Acute pain r/t surgical incision due to cesarean birth as evidenced by facial grimace with pain scale of 7.

PLANNING / DESIRED SHORT TERM:


OUTCOMES • After 4 hours of effective nursing interventions, the patient will be able to experience lesser pain and above a tolerable level as
manifested by:
a. Pain scale at least 4/10
b. No facial grimace
c. Slight irritability
LONG TERM:
• After 72 hours of effective nursing interventions, the patient will:
a. Achieve timely wound
b. Free of infection
c. Able to move without much assistance from others

INTERVENTIONS • Identified the cause of pain.


(To know what interventions to do)
• Administered medicine for pain PRN ordered by physician / staffs.
( To relieve pain)
• Monitored vital signs.
(To establish baseline data)
• Assessed quality, characteristics, severity of pain.
(To establish baseline data for comparison in making evaluation)
• Advised the patient to do breathing exercise.
(To decrease discomfort)
• Advised increased intake of iron and vitamin C.
(To boost immune system and reduce the risk of suffering from iron deficiency)
• Advised to increase intake of protein after soft diet.
( Helps your body build muscle, and it can help you heal after surgery.)
• Encouraged to apply cold compression on surgical site during pain.
(To relieve pain)
• Encouraged the patient to increase fluid intake, as indicated.
• Encouraged early ambulation and mobilization
(To promote circulation)
• Let the patient or couple verbalized their inner thoughts and feelings.
(Provides a chance to cope with uncertain or unresolved feelings of grief.)
• Discuss with family ways to assist the patient and reduce the pain.
(Emotional and psychological support provided by the family can help in recovery and reduce POSTCS pain.

EVALUATIONS SHORT TERM: (GOAL MET)


• After 4 hours of effective nursing interventions, the patient was able to experience lesser pain and above a tolerable level as manifested
by:
a. Pain scale at least 4/10
b. No facial grimace noted.
c. Calm and cooperative

LONG TERM: (GOAL MET)


• After 72 hours of effective nursing interventions, the patient achieved timely wound healing, free of infection and was able to move
without much assistance from others.

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