C-section concept map

[astronautswife]

Hello! I am in my OB clinical rotation and am working on my C-Section concept map. For my nursing diagnosis I have:

1. Acute Pain r/t surgical incision

2. Risk for impaired tissue perfusion: cardiopulmonary r/t blood loss

3. Risk For Infection r/t surgical procedure and hospitalization

+ 17 other diagnoses.

I have all of my nics and nocs for the 3 diagnosis but I just am having a hard time with #2 -I have for assessment:

HR, BP, HS, RR, capillary refill, quality of pulse ??

But as far as Meds/Tmts and Diagnostic tests for Risk for impaired tissue perfusion as it relates to a Csection patient-I'm just not sure. Any thoughts or clues to get my brain working would be very much appreciated!

[Daytonite, BSN, RN]

This patient had surgery, had either epidural or general anesthesia. She may or may not have been in labor (you didn't say) and may or may not be breastfeeding (you didn't say). This could be her first baby (you didn't say). Those are all important assessment things to know in order to diagnose this patient's nursing problems. That is all important assessment data. How is she walking? Is she getting up and moving? Has she had a BM since surgery? Is she eating solid foods yet? How are her lungs sounds? The complications of epidural anesthesia are

• hypotension
  
• 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

Does she have any symptoms of any of these? You can't have "Risk for" diagnoses unless there is a risk for a problem or complication that could happen. Risk for Impaired Tissue Perfusion has to do with tissue hypoxia due to compromised circulation. What circulation problem does she have? Hemorrhage is a fluid loss problem if that is what you were going for. There is are three diagnoses for breastfeeding (Effective, Ineffective and Interrupted). What teaching needs to be done, especially regarding wound care upon discharge (Deficient Knowledge, specify)?

[astronautswife]

Sorry, I forgot to mention that there is no real patient-this is just for any postpartum C-Section. So the diagnoses are just any three that I would potentially find in any C-Section. Thanks!

[Daytonite, BSN, RN]

this is primarily a surgical patient. go to the surgical section of your regular nursing textbook and re-read the parts about incision care, pain, ambulation after abdominal surgery. these patients have their lower abdomen cut into. peristalsis stops. they are on iv fluids and npo (possible deficient fluid volume) until peristalsis returns. that is a nursing problem. look up the signs and symptoms of an ileus. constipation goes right along with that. abdominal surgery patients don't get discharged until they pass gas and poop. a c-section is no different. she is going to have questions. can i shower? when can i shower? when will the staples/sutures be taken out? this is all teaching that needs to be done. some of these women will have a body image problem because of the scar they are going to have.

[astronautswife]

Thanks Day-I am rethinking my top three diagnosis now! Thanks so much for taking the time out to respond.