NURSING CARE PLAN

By: Lyka Joy V. Davila

Case Scenario....
Caesarian Section
Kristine Lim, 34 year old female, gravida 4, para 3 with 41 weeks of high pregnancy from Dungon B, Jaro, Iloilo City admitted in
the Emergency room. According to patients history, she has reported abdominal pain, edema in the feet and legs. The patient is
morbidity obese, with IVF of D5LR 1L for 8h, with abnormal or indeterminate fetal heart rate tracing. Dr. Cadate schedule her for stat
Caesarian section and the husband suggested Dr. Ane as the anesthesiologist of choice.

The ER nurse hand off report to the circulating nurse, Jennifer Cacho at 12:15 p.m. Preoperative checklist and informed consent
reviewed and transferred patient to Major room 2. The scrub nurse, John Huele help the patient to position in the OR table.

The operation started at 12:30 p.m. and ended at 1:35 p.m.

Dr. Cadate write the postop diagnosis, PUFT delivered via Repeat LTCS to a live baby girl in cephalic presentation, G4P4 (4004)
Gestational hypertension

POSSIBLE NURSING DIAGNOSIS:

1. Decreased Cardiac Output related to decreased venous return as evidenced by verbalization of edema of the lower
extremities, morbidity obese, and abnormal/indeterminate fetal heart rate
2. Risk for Infection related to tissue trauma secondary to surgical procedure.
3. Risk for Injury related to regulatory functions (development of gestational hypertension)
Name: K.L Age: 34 years old Sex: Female
Address: Dungon B, Jaro, Iloilo City Chief Complaint: abdominal pain, edema in the feet and legs Admitting Diagnosis: Gestational Hypertension

CLUSTERED NURSING OUTCOME NURSING RATIONALE EVALUATION DISCHARGE

CUES DIAGNOSIS CRITERIA INTERVENTIONS PLANNING
Subjective:
Decreased Short term Goal: Independent Short Goal: MEDICATION
“Gasakit akon Cardiac After 3 hours of 1. Establish rapport. 1. To gain patient trust Met. After 3 hours Instruct the patient to take
pus-on kag Output related nursing and cooperation. of nursing home post operative
gapalanghabo to decreased interventions, the medications as prescribed
2. Monitor and assess 2. To obtain baseline interventions, the
k akon mga tiil venous return patient will display by the physician. Discuss
heart rate and blood data for comparison
patient displayed
kag batiis.”
as evidenced hemodynamic the desired effects and side
pressure. to follow trends and
hemodynamic
by stability as effects of the medications.
evaluate response to
stability as
Objective:
verbalization evidenced by a Clarify if there are any
intervention. evidenced by
> Morbidity of edema of decreased edema questions about the
Obese
the lower on the lower leg, 3. Observe skin color, 3. Cold, clammy, pale decreased edema, physician’s orders.

> Abnormal / extremities, FHR and BP within moisture, temperature skin, and delayed FHR=148bpm,
indeterminate morbidity normal range.
and capillary refill capillary refill may be BP=130/80mmHg. ENVIRONMENT
fetal heart obese, and time. due to peripheral Instructed the patient and
tracing
abnormal/ vasoconstriction or family members to keep her
indeterminate cardiac environment clean, calm,
fetal heart decompensation. well ventilated and must be
rate. free from slipping or
4. Auscultate and 4. To allow constant
accident hazards.

monitor the fetal heart assessment of fetal

tone. well-being.
TREATMENT
Informed patient about the
medical treatment and
management to be
observed after surgery.
CLUSTERED NURSING OUTCOME NURSING RATIONALE EVALUATION DISCHARGE
CUES DIAGNOSIS CRITERIA INTERVENTIONS PLANNING
management to be
5. Position the patient 5. This position observed after surgery.
on her left side or decreases occlusion Instructed to follow regimen/
place a towel under of the inferior vena therapy as prescribed by
hips. cava by displacing 
 physician to promote fast
the uterus, promoting
healing process and
venous return to the recovery.

heart.
HEALTH EDUCATION
6. Anticipate and 6. To expedite
Instructed patient to avoid
prepare the patient for termination of
lifting of heavy objects for
cesarean section threat to mother and
1-2 weeks. Stress the
delivery. the fetus. importance of perineal
cleanliness and proper
dressing of wound.
Dependent Encouraged patient to have
1. Administer D5LR 1. Expands circulatory hot sitz bath.

1L x 8H as volume, especially
ordered. Give IV prior to administration OUTPATIENT FOLLOW-UP
bolus as of epidural/spinal Instructed the patient and
necessary. anesthesia. family member when to
return for follow-up check.
2. Administer 2. To increase oxygen Stress to call the physician
supplemental oxygen available for maternal to report if any problem is
via face mask at a and fetal uptake. identified such as having
flow rate of 10 L per severe pain, even after
minute or as taking a medication or for
indicated. any signs of infection.

CLUSTERED NURSING OUTCOME NURSING RATIONALE EVALUATION DISCHARGE

CUES DIAGNOSIS CRITERIA INTERVENTIONS PLANNING
any signs of infection.

Collaborative
1. Collaborate with 1. To assist with DIET
the OR patient for surgery, Instructed patient to
department note alterations in increase intake of protein
(Surgical team) vital signs, and rich foods such as beans,
about patient prevent eggs, fish, to promote faster
findings and complications.
wound healing. Instructed to
assessment.
eat vitamin C rich foods
such as citrus fruits,
vegetables, and berries to
2. Refer patient to a 2. To assist patient in help the body make
dietitian.
developing a plan collagen for fast recovery.
to determine Instructed to promote
caloric and adequate fluid intake and
nutrient increase intake of fiber to
requirements for avoid constipation. Limit
individuals weight sodium, fat and cholesterol.

loss and reduce

complications. SOCIAL SUPPORT
Encourage the patient and
family members to surround
themselves with support
persons and do not hesitate
to ask for help.

SPIRITUALITY
CLUSTERED NURSING OUTCOME NURSING RATIONALE EVALUATION DISCHARGE
CUES DIAGNOSIS CRITERIA INTERVENTIONS PLANNING
SPIRITUALITY
Advise the patient and

family to seek spiritual

comfort according to

religious denominations
during the recovery and
healing process.

REFERENCES:

NursesLabs.com. (2019). Decreased cardiac output eclampsia. Scribd. https://www.scribd.com/doc/

25758950/Decreased-Cardiac-Output-Eclampsia?
fbclid=IwAR2AVkDeWW5HKJNn1bPSIpBi8NnC1jD5AsyL9coUBHOt4brJBxMpMP-V9DI

Wayne, G. B. (2019). 10 cesarean birth nursing care plans. Nurseslabs. https://nurseslabs.com/cesarean-

birth-nursing-care-plans/9/

Wayne, G. B. (2021). Decreased cardiac output nursing care plan. Nurseslabs. https://nurseslabs.com/
decreased-cardiac-output/