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1. The patient is at risk for infection due to the presence of catheters and a post-surgical abdominal incision. 2. The patient is at risk for imbalanced fluid volume due to decreased urine output of 160ml with an IV and Foley catheter present. 3. The patient is at a risk for constipation due to insufficient physical activity following a cesarean section with limited range of motion and an NPO diet.

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Katrine
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766 views

Concept Map

1. The patient is at risk for infection due to the presence of catheters and a post-surgical abdominal incision. 2. The patient is at risk for imbalanced fluid volume due to decreased urine output of 160ml with an IV and Foley catheter present. 3. The patient is at a risk for constipation due to insufficient physical activity following a cesarean section with limited range of motion and an NPO diet.

Uploaded by

Katrine
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Nsg Dx #2: Risk for infection r/t post

surgical procedure secondary to presence Nsg Dx #3: Risk for imbalanced fluid
of contraptions volume r/t decrease in normal urine
output
Objective cues: Initials: S.DT.L
Patient’s Medical Diagnosis: Low Transverse Cesarean section 1ْ
- 30 years old Objective cues:
oligohydramnios
- G1P1 (1001) - Vital signs: temperature - 37ْ C, PR –
- Vital Age:
signs:30temperature
years old - 37ْ C, PR – 82Gender: Female 82 bpm,ofRR
Basis for prioritization: Maslow’s Hierarchy – 18 cpm, BP – 100/70
needs
bpm, RR – 18 cpm,
Category: I BP – 100/70 mmHg Room no.: 609B Date admitted: July 23, 2009 mmHg
Student nurse: Valdez, Katrine
- (+) Foley catheter - total urine output: 160ml
- (+) IV Fluid and side drip - (+) Foley catheter
- Lochia: red, (-) foul odor - Diet is NPO
- (+) abdominal incision MDx: Low Transverse Cesarean section 1ْ - (+) IV fluids
- (-) fever oligohydramnios

Priority Assessment:

o Vital signs
o Age
o OB history
o Nutrition and Diet
o Skin Condition
Nsg Dx#4: Risk for constipation r/t
Nsg Dx #1: Impaired skin integrity r/t o Vaginal Discharge insufficient physical activity
surgical procedure aeb presence of o Contraptions
abdominal incision o Intake and output Objective cues:
o Activity - Vital signs: temperature - 37ْ C, PR –
Objective cues: o Bowel Movement 82 bpm, RR – 18 cpm, BP – 100/70
- 30 years old mmHg
- Vital signs: temperature - 37ْ C, PR – 82 - (+) flatus
bpm, RR – 18 cpm, BP – 100/70 mmHg - (-) Bowel movement
- G1P1 (1001) - Diet is NPO
- (+) abdominal incision - Limited ROM
- Skin is rarely moist
- Limited ROM

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