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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 crease worries. . Requires decrease analgesia such as Panola 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. 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 improved comfort in abdomen, as evidenced by 1 Stating a decrease in rating of abdominal pain. 2.
Being able to rest, display reduced tension, and sleep comfortably with decreased worries. 3. Requiring decreased analgesia such as Panola Long term goal: The woman had an improved feeling and free of anxiety as evidenced by verbalizing comfort over present situation and future outcomes with two days of intervention. Nursing care plan Name of client: Miss Eng Sex: Date of assessment: 31/10/2014 Medical diagnosis: Caesarian section Diagnostic statement: Readiness for enhanced knowledge in breastfeeding as evidenced by decrease of infant’s weight
Subjective data: 1 . The woman is frustrated and she verbalized her anxiety. 1 The weight of infant decreased by 7%. 2. The intake of mothers milk is less than 15 ml. 3. The infant cries and is reluctant to eat. Problem: Readiness for enhanced knowledge 2. In breastfeeding Signs and symptoms: 1. Decreased of infants weight. The woman will reduce level of frustration and the weight of infant Will increase. Short term expected outcome: control of breastfeed.