Cesarean Section Care Plan

[tsprink72]

I have to do a care plan for a patient who had a c-section for failure to progress. She had no pain. She was hispanic and her husband had to translate for her. She had not had a bowel movement in 3 days. I know that Impaired tissue integrity would be one of my nursing dx. I think that the language barrier would be one and the bowel movement but I'm not sure. Can anyone help? Our teacher expects every nursing dx, not just the most important. Any help would be appreciated.

[casi, ASN, RN]

pain

impaired coping/mourning whatever it is, a lot of women look forward to vag deliveries

what about all the parenthood family stuff?

[Student Mom to Three]

Prior to section:

Anxiety

Knowledge deficit

During section:

Risk for injury

Nausea (?)

After section:

Pain

Risk for infection (incision, epidural puncture, cath)

Risk for falls (epidural)

Nausea (?)

Those are some I thought of that are very general. Of course, all diagnoses must be patient specific, so these may or may not apply and there could be a bunch of others that fit your patient perfectly.

[LobotRN, BSN, RN]

Remember that this patient is essentially undergoing major abdominal surgery. Look up careplan/map information on that and that will identify your physiologic integrity needs (think things like blood loss during surgery/after surgery can lead to fluid volume deficit....hence RN will monitor VS q15 x 1 hr (and continue per protocol) for s/s of fluid volume deficit such as low BP and tachycardia, etc.)......maybe a little risk for dehiscence or evisceration? Kind of extreme, but the incision goes through all layers into the abdominal cavity.....

There is also risk for impaired ventilation due to post surgical pain (who wants to deep breathe when your gut aches like crazy and you're tired?), so the RN will teach the pt. importance of Turn, Cough, Deep Breathe (TCDB) and use of incentive spirometer......

Constipation.....no bm in 3 days? RN will encourage early ambulation and administer stool softeners per protocol and encourage hydration unless contraindicated.

These just come to mind, but there is a lot more in the care of a post surgical pt.....Take a look at your nursing diagnosis text book or at the website for the publisher of your nursing texts and see if they have sample plans available.

Good luck! And like "casi" said, remember the psychosocial as well.

[CEG]

Don't forget breastfeeding and parenting. C/s patients are more at risk for breastfeeding problems and challenges taking care of the baby in the inital postpartum period.