ncp post cs
TRANSCRIPT
-
7/27/2019 NCP Post CS
1/5
ASSESSMENTNURSING
DIAGNOSISPLANNING
NURSINGINTERVENTION
RATIONALEEvaluation
SubjectiveNurse, parangmainit ung nanayko as verbalizedby the relative ofthe patient.
Objective
Temperature:
38.6C
RR: 26cycle
per minute
Hot, flushed
skin
Increased
respiratoryrate
Diaphoresis
Warm to
touch
Hyperthermiarelated to bacterialinfection.
Definition:Body temperature
elevated abovenormal range.
Short TermAfter 1 hour ofappropriatenursingintervention thepatients
temperature willdecrease to37.5oC.
Long TermAfter 4 hours ofappropriatenursingintervention thepatients vital
signs will return tonormal range; witha temperature of36.5-37.5oC,pulserate of 60-100bpmand respiratoryrate of 12-20cycles per min.
Independent1. Monitor vital
signs.
2. Provide tepidsponge bath.Do not usealcohol.
3. Remove excessclothing andcovers.
4. Promote a well-ventilated area
to patient.
5. Advise patientto increase oralfluid intake.
6. Maintain bedrest.
Vital signs
provide moreaccurateindication of coretemperature.
TSB helps in
lowering thebodytemperature andalcohol cools theskin too rapidly,causingshivering.Shivering
increasesmetabolic rateand bodytemperature
These decrease
warmth andincreaseevaporativecooling.
To promote clear
flow of air in thepatients area.One way ofpromoting heatloss.
Additional fluids
help preventelevatedtemperatureassociated with
Short TermAfter 1 hour ofappropriatenursingintervention thepatients
temperaturedecreased to37.5oC.
Long TermAfter 4 hours ofappropriatenursingintervention thepatients vital
signsl return tonormal range;with atemperature of36.5-37.5oC,pulse rateof 60-100bpmand respiratoryrate of 12-20cycles per min.
-
7/27/2019 NCP Post CS
2/5
ASSESSMENT NURSING
DIAGNOSIS
PLANNING NURSING
INTERVENTIONS
RATIONALE EVALUATION
Subjective:Mainit angpakiramdam koas verbalized by
the patient.Objective:
Flushed skin,
warm totouch.
Restlessness
.
V/S taken as
follows:T: 38.1P: 70R: 19BP: 110/90
Hyperthermiarelated todehydration
After 4 hrs. Ofnursinginterventions,the patient will
maintain coretemperaturewithin normalrange.
Independent:
Monitor heart
rate andrhythm.
Record allsources of fluidloss such asurine, vomitingand diarrhea.
Promote
surface coolingby means of
Dysrhythmiasand ECGchanges are
common dueto electrolyteimbalanceanddehydrationand directeffect ofhyperthermiaon blood andcardiactissues.
To monitor orpotentiatesfluid andelectrolyteloses.
To decrease
temperatureby means
After 4 hrs.Of nursinginterventions, the
patient wasablemaintaincoretemperaturewithinnormalrange.
-
7/27/2019 NCP Post CS
3/5
tepid spongebath.
Wrap
extremities withcotton blankets.
Provide
supplementaloxygen.
Administer
replacement fluids
and electrolytes.
Maintain bed
rest.
Provide high
calorie diet,tube feedings,or parenteral
nutrition.Administer
antipyreticsorally or rectallyas prescribedby thephysician.
throughevaporationand
conduction.
To minimize
shivering.
To offset
increasedoxygendemands andConsumption.
To supportcirculatingvolume andtissueperfusion.
To reduce
metabolicdemands andoxygenconsumption
To increased
metabolicdemands.
To facilitate
fast recovery
-
7/27/2019 NCP Post CS
4/5
ASSESSTMENT NURSING
DAIGNOSIS
PLANNING NURSING
INTERVENTION
RATIONALE eVALUATION
Subjective:
Parang mainit
ang pakiramdam
ko as verbalizedby the patient.
Objectives:
BP- 120/80mmhg
PR- 90bpm
RR19cpm
Pallor
Increased risk of
infection related to
post CS as
manifested by
increased bodytemperature.
After 8 hours of
nursing
intervention the
patients body
temperature willbecome stable.
Establish rapport
Perform TSB
Provide healthteaching such as:
1. avoid evcessive
clothing that
covers the
body.
2. maintain proper
hygiene
To promote
trust.
To minimize
bodytemperature.
1. to give comport
to the patient
and feel more
comfortable.
2. To avoid
infection
After 8 hours of
nursing
intervention the
patients body
temperaturebecome stable.
-
7/27/2019 NCP Post CS
5/5