C section patient

  1. 0
    Hi everyone,
    I have a patient who had a c-section and I have to write nursing care plan for this Pt. I already come up with three Nursing diagnosis
    Risk for Infection r/t abdominal incision and foley catheter
    . Acute pain r/t C- section
    Risk for constipation due to decreased activity, pain medication, general anesthesia, decreased G.I. motility, decreased intake of fiber and liquids and, incisional pain.



    And i want to write something about risk for thrombophelibitis But I am not sure what could be the nursing diagnosis for this? Any suggestions?
    thanx in advance

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  2. 4 Comments...

  3. 0
    Don't forget the ones such as "Anxiety r/t ..." The psychsocial ones are important too
  4. 0
    Quote from adidasgirl0699
    Don't forget the ones such as "Anxiety r/t ..." The psychsocial ones are important too
    :yeahthat:

    Don't forget disturbed body image...
    Take it from someone who has had 3 c-sections. You are no longer pregnant, but if you pass someone on the street they would think that you still were-- belly still distended... kinda like a jelly doughnut without some of the filling!

    Oh and for any new parent... disturbed sleep pattern.
  5. 0
    OOOps
    Last edit by MelodyRNurse on Mar 11, '07 : Reason: mistake
  6. 0
    mani3433. . .you will have three anticipatory diagnoses and only one diagnosis for only one real problem! your instructor is going to have field day with you! you want to care plan for real problems.

    first of all, this is a post-op patient subject to all the complications a post-op patient can get depending on the type of anesthesia. how are you addressing her recovery from the epidural (i'm assuming that what's she had?) also, you aren't addressing the incisional wound at all and that is impaired skin integrity. you would include interventions to monitor for infection of the surgical wound under that diagnosis. is there still an iv or saline lock in place? this is a source for a safety issue related to monitoring for phlebitis. did this patient have any problems with voiding? it is not usual for post-op c-section patients to have problems with urinary retention due to (1) swelling of the tissues in the surrounding area from surgical manipulation or prolonged labor, or (2) secondary to the effects of drugs of anesthesia. even with epidural anesthesia there is a likelihood for postop complications with hypoactive bowel and constipation. the abdomen needs to be assessed frequently for this and not until the patient has had a bowel movement can you be sure that there isn't a constipation problem. there is always a knowledge deficit (learning need) with regard to wound care, physical activity and hygiene that will need to be addressed prior to discharge, even if this is not the patient's first c-section. what about fatigue? while most new mothers are usually elated, once company and visitors are gone, they usually are dog tired, especially if they're full of pain medication. and, how is that affecting the mother's performance with the baby and feedings? is she breastfeeding? there are several diagnoses for breastfeeding. if all is going well with that, use effective breastfeeding r/t maternal confidence (this is an actual nanda-i nursing diagnosis).

    the diagnosis you are searching for with thrombophlebitis is risk for injury r/t effects of anesthesia or tissue trauma. if your patient was given oxytocin to help induce labor and delivery or had an long labor prior to the c-section the risk of thrombophlebitis increases. also, decreased mobility related to the postoperative pain will also be a risk factor. however, if there is a mobility problem, i would go with a diagnosis for impaired physical mobility r/t incisional pain first. you can always include nursing interventions to monitor for phlebitis under that diagnosis.


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