A.

Nursing Problem Prioritization

Level of Date Identified Cues Nursing Diagnosis Justification/Bases in Prioritizing the Problem
Priority

I 11/16/2023 Subjective: Acute Pain related to The client has reported experiencing pain at the
surgical incision due to surgical incision site, thus, prioritizing this issue
"Masakit banda sa cesarean birth as evidenced is crucial. Furthermore, postoperative pain,
may tahi ko" as by facial grimace with a pain particularly following a cesarean section (CS),
verbalized by the scale of 5/10 can impact the patient's comfort, mobility, and
client. ability to engage in essential activities such as
Objective: breastfeeding and bonding with the newborn.
By giving priority to pain management,
- Pain Scale: 5/10 healthcare professionals strive to improve the
- Facial Grimace patient's experience and promote a more
seamless recovery process.
Vital Sign taken:
- BP: 140/120
- PR: 103
- RR: 20
- Temp: 36.9
II 11/16/2023 Subjective: Impaired Skin Tissue The human body has a strong defense
Integrity related to cesarean mechanism against any external dangers. The
“Nahihirapan ako section skin, which is the biggest organ in the human
sa tahi ko” as body, makes up a significant portion of this
verbalized by the system. Through this, the body is shielded from
client. heat, light, pollution, traumas, and diseases.
Objective: However, the integrity of the skin layer is
jeopardized when wounds such as cuts, rashes,
- Destruction or abrasions affect the skin. We refer to this as
of skin layers
- Disruption of impaired skin integrity.
tissue layers.
- (+)Redness Prioritizing impaired skin tissue integrity in
on the patients is important because it serves as a
incision site. frontline defense against infections, promotes
- (+)Swelling overall health, and accelerates the healing
on the
process. Neglecting skin integrity can lead to
incision site
complications such as infections, delayed
wound healing, and increased healthcare costs.
Additionally, maintaining skin health is
essential for the patient's comfort and quality of
life.