I need a nursing Dx for C-section in PACU...

  1. I can't use Risk for Infection because it is too soon. It has to be while in PACU. She had an epidural and was in NO pain. Lower transverse abdominal incision with scant bleeding on the peripad, however, she did lose 650ml of blood during surgery. What would you guys pick as your #1 Dx? My instructor is very anal about these caremaps and I want it to be good. Thanks for looking.
    Cindi
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  2. 15 Comments

  3. by   Clarise
    1. Pain
    2. Impaired urinary elimination (due to anesthesia)
    3. Anxiety - worried about her baby, if she was under general anesthesia, she might not have seen her baby yet.
  4. by   Imafloat
    Could you throw a fluid volume defecit in there?
  5. by   szelda
    (Risk for) Fluid Volume Deficit
    (Risk for) Impaired Skin Integrity
    Activity Intolerance
    Self-Care Deficit
    Risk for Constipation (due to immobility post-anesthesia)
    Risk for Falls (due to immobility post-anesthesia)
    Risk for Injury
    Impaired Physical Mobility
  6. by   moongirl
    Def go with fluid volume deficit, this can be blood loss or from being dehydrated before C Section
    and even if she is feeling no pain, she is still at risk for it
  7. by   MegNeoNurse
    Any type of "risk for" nursing diagnosis should never be a #1 in this case, as there are higher priorities. Our nursing instructors always told us that "risk for" are never #1 unless there are no other applicable Dx. I would go with acute pain r/t surgical incision (she WILL be in pain), disturbed body image r/t surgery, impaired comfort r/t side effects of epidural narcotics, or impaired physical mobility r/t pain for your #1.
  8. by   Daytonite
    cindi. . .your patient just had an invasive surgery. she is a post-operative patient even though she is also a postpartum patient. think about the common concerns and observations you need to be making in someone who has just had a laparotomy and epidural anesthesia. potential complications include hemorrhage, hypovolemic shock, evisceration, dehiscence, peritonitis, urinary retention, thrombophlebitis, paralytic ileus, incisional pain, and fluid loss. was there an episiotomy? they are wounds that can develop complications such as swelling, hemorrhage and dehiscence immediately after delivery. when patients are lying on operative tables with open incisions they lose fluids into the atmosphere. that fluid loss combined with blood loss can lead to shock. with epidural anesthesia the major side effect includes hypotension. nursing care for this patient in the pacu includes monitoring her vital signs, turning, coughing and deep breathing, watching for first urination and any signs of uti or retention, that the fundus is reducing and observing for early signs of a thrombophlebitis.

    there are 2 main nursing diagnoses you should use:

    (1) impaired tissue integrity r/t surgical disruption of tissues aeb surgical incision and episiotomy
    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=54
    http://www1.us.elsevierhealth.com/ev...replan_071.php

    (2) although your patient isn't stating she is having pain, she has an incision, is still under the effects of the epidural and may or may not have pca analgesia running. that still warrants a nursing diagnosis of acute pain because nursing interventions need to be instituted and carried out to assess and monitor pain levels, educate and instruct the patient in how the pca equipment works, and manage the pca. i've just given you 3 nursing interventions for acute pain r/t surgical intervention. http://www1.us.elsevierhealth.com/me...ex.cfm?plan=40
    http://www1.us.elsevierhealth.com/ev...replan_052.php

    other nursing diagnoses to consider would be:

    ineffective tissue perfusion: cardiopulmonary r/t blood loss and effects of epidural anesthesia aeb [any signs or symptoms of shock]
    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=55
    http://www1.us.elsevierhealth.com/ev...replan_072.php

    impaired urinary elimination r/t surgical manipulation of surrounding gynecologic structures and post epidural effects aeb no first voiding since c-section
    http://www1.us.elsevierhealth.com/ev...replan_073.php


    impaired parent/infant attachment r/t separation from infant while in pacu aeb [statements or observed anxiety relating to dysfunction of normal nuturing and protective behaviors for infant]
    http://www1.us.elsevierhealth.com/ev...replan_007.php
  9. by   Lisa CCU RN
    Why is she not at risk for infection? Any incision is at risk for that.
  10. by   Daytonite
    Symptoms of infection won't usually appear right away. It is likely the patient was given IV antibiotics so the question of infection has probably been covered by the doctor. Remember the pathophysiology of infection. The progression of infection is to go from the inflammation response to infection. You need to be doing incision assessment for redness, swelling or presence of purulent drainage which are symptoms of infection for any post-op. These actions will be done as nursing interventions under the nursing diagnosis of Impaired Tissue Integrity. The patient's surgical incisions should be consistently and regularly evaluated from the time they leave the surgical suite. This includes the observation, assessment, and monitoring of these wounds for signs and symptoms of inflammation and infection, as well as for hemorrhage. These are legitimate nursing interventions that also cover the patient's risk for infection without actually using that nursing diagnosis. There is always more than one way to skin a cat, so to speak, when working with nursing diagnoses.
  11. by   Lisa CCU RN
    Quote from Daytonite
    Symptoms of infection won't usually appear right away. It is likely the patient was given IV antibiotics so the question of infection has probably been covered by the doctor. Remember the pathophysiology of infection. The progression of infection is to go from the inflammation response to infection. You need to be doing incision assessment for redness, swelling or presence of purulent drainage which are symptoms of infection for any post-op. These actions will be done as nursing interventions under the nursing diagnosis of Impaired Tissue Integrity. The patient's surgical incisions should be consistently and regularly evaluated from the time they leave the surgical suite. This includes the observation, assessment, and monitoring of these wounds for signs and symptoms of inflammation and infection, as well as for hemorrhage. These are legitimate nursing interventions that also cover the patient's risk for infection without actually using that nursing diagnosis. There is always more than one way to skin a cat, so to speak, when working with nursing diagnoses.
    I realize that the signs and symptoms may not appear immediately, but how does that negate the patient being at risk for infection?

    I have been putting this diagnosis all semester for my patient's and I'm on a post-op floor. We only have to put done one diagnosis for now since we have three patients. So, in the reality, I should be putting impaired tissue integrity or does it really matter? I guess that one would be a cover all dx. I usually put risk for inefective breathing pattern if the pt. has an abdominal surgery.
  12. by   Daytonite
    CRNASOMEDAY25. . .my understanding of the OPs question was that she had to work within the parameters of the patient being in the post anesthesia recovery room, which is the very immediate post surgical period. Patients in PACU are primarily being assessed for shock, hemorrhage and complications from the anesthesia.
  13. by   PANurseRN1
    (Risk for) Impaired Skin Integrity
    Activity Intolerance
    Self-Care Deficit
    Risk for Constipation (due to immobility post-anesthesia)
    Risk for Falls (due to immobility post-anesthesia)
    Risk for Injury
    Impaired Physical Mobility
    These are not relevant to PACU.
  14. by   Lisa CCU RN
    Quote from Daytonite
    CRNASOMEDAY25. . .my understanding of the OPs question was that she had to work within the parameters of the patient being in the post anesthesia recovery room, which is the very immediate post surgical period. Patients in PACU are primarily being assessed for shock, hemorrhage and complications from the anesthesia.
    Gotcha.

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