So, these are the responses, signs and symptoms you observed in this patient:
- doesn't go to work and receives her support from WIC
- lives by herself with the kids
- Group B Strep positive
- desires to use contraceptives when she goes home (even after her tubal ligation)
- reports pain around her incision site and grimaced when i felt for the fundus. I asked her what her pain was and she said maybe a 1-2 on scale of 10
- complains of gas
- I did notice how she wanted to hold the baby when the adoptive parents were in the room and even fed the baby with a bottle and changed his diaper
You have to remember that this lady has had surgery and although she is a pospartum patient, she is also a surgical patient. You need to go back to your med/surg textbook and review the care of the general surgical patient because it applies here. If she had general anesthesia, you need to be watching and monitoring for signs and symptoms of complications of general anesthesia:
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection)
- fluid and electrolyte imbalances
- urinary retention
- surgical pain
- nausea/vomiting (paralytic ileus)
If she had an epidural, you need to be monitoring for signs and symptoms of complications of epidural anesthesia:
- rash around the epidural injection site
- nausea and vomiting from the opiates administered
- pruritis of the face and neck caused by some epidural narcotics
- respiratory depression up to 24 hours after the epidural
- cerebrospinal fluid leakage and spinal headache from accidental dural puncture
- sensory problems in the lower extremities
In addition, you need to look up information about the cesarean section procedure itself. You need to be aware that the following are risks of this procedure:
- infection (what's this Group B Strep positive thing about? What was cultured and tested positive?)
- urinary tract trauma
- paralytic ileus
- anesthesia complications
When the abdomen is cut into and the bowel is in any way disrupted or touched, peristalsis which is a continual muscular motion in the GI tract, shuts down immediately. Ileus and nausea result. It takes a little time for peristalsis to get restarted and it takes several weeks for it to return to normal. If the patient's bowel was prepped (enemas to cleanse and empty the bowel), then the now quiet and motionless bowel fills with gas because of the normal presence of bacteria in the large intestine. The first symptoms you may see are a distended abdomen and nausea. When peristalsis returns, you assess for bowel sounds, the patient passing gas and finally having the first BM. One of your patient's symptoms is that she has gas. I have no doubt that some of her pain is related to the gas building up in her colon. When, I wonder was her first BM since her surgery?
Is this lady having any problems with ambulating? You didn't say. Usually with an incision like this women are reticent to get up and move around as they normally would which would warrant a diagnosis of either Impaired Physical Mobility
or Activity Intolerance
depending on the symptoms they have.
If she has pain and is getting pain medications and there are comfort measures that can be done for the incisional pain, the Acute Pain
To my way of thinking, an incision warrants a diagnosis of Impaired Tissue Integrity
, but not everyone agrees with that. I worked on surgical units and this diagnosis was on every surgical patient's care plan.
I found it interesting that this patient desires to use contraceptives when she goes home even though she has had a tubal ligation. That sounds bizarre to me. Unless there is something I don't know about tubals, she doesn't need contraceptives anymore. It also tells me that she needs some teaching and information about the procedure and the risk of pregnancy. That's a Knowledge Deficit, tubal ligation.
You noticed that she wanted to hold the baby when the adoptive parents were in the room, fed the baby and changed his diaper. Do you suppose she has some separation or coping issues? I was thinking that she may not be ready to give this baby up. What do you think? It's also interesting that she knows the people she's giving the baby up to--keeps a tie to the baby for her, doesn't it? Decisional Conflict
or Risk for Decisional Conflict
?Wouldn't be the first time a mother changed her mind and might be having second thoughts.
Beyond that, unless you want to do some "Risk for" diagnoses for some of the complications listed above. I wouldn't address any of her psych problems. They are not what she is in the hospital for. This is an OB rotation and I'm betting that your instructor is going to be much happier if you address the OB problems which she does have.
Your nursing interventions address the symptoms that support each of the nursing diagnoses.