First of all, let's work through the pathophysiology of what is going on with this patient. A patient who has had a C-section has had a surgery where some sort of anesthesia was used (I'm assuming an epidural). Was the decision to do the C-section made after the patient was already in labor? Or, was this a planned C-section? What are the common complications for the type of anesthesia that was used and was the patient thoroughly assessed for any of the symptoms of them? If the patient was in labor as well, then there was muscular activity involving the uterus. The pushing of the baby against the pelvic structures creates some trauma to the mother's tissues. When there is any kind of trauma, even the smallest boo-boo, the body responds by initiating protective protocols. The result is the local tissues swell as the blood supply to the area increases. Swollen tissues create some problems, particularly if they are pushing against other tissues and organs. So, you have to keep in mind the organs that are contained in the pelvic area that are subject to this (urinary bladder, part of the large intestine, genital organs). With surgical intervention these same protective responses of the body are going to be initiated because there has been a foreign invasion by the surgeon with mechanical manipulation of the tissues.
Here is a list of the common complications of surgical patients undergoing 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)
Complications of epidural anesthesia are:
- 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
You have a incision. Impaired Skin Integrity R/T surgical intervention
is an appropriate diagnosis to use. Your nursing interventions under this diagnosis would include monitoring and care of the surgical incision.
should be considered a problem due to swelling of the internal tissues until the patient passes their first stool. If your patient is not passing gas, then it is likely that she is going to be constipated considering the amount of narcotics she got during the C-section. Likewise, until the patient is voiding adequately, urinary problems need to be watched for. If the mother was in labor before the C-section and doing some pushing, there may be hemorrhoids that need attention.
If the mother is breastfeeding, there are several nursing diagnoses that address this for both the mother who is breastfeeding without problems and those who are having problems: Effective Breastfeeding, Ineffective Breastfeeding,
and Interrupted Breastfeeding.
Was there blood loss during surgery? What was the patient's fluid status prior to surgery? What about after surgery? Were there any food or fluid restrictions? The consideration of a nursing diagnosis of Deficient Fluid Volume
is most appropriate.
With surgical invasion there is often Acute Pain.
After labor and delivery and/or C-Section mothers are usually pretty fatigued. There is a nursing diagnosis for this: Fatigue.
If you really want to get fancy there are also these nursing diagnoses:
- Knowledge Deficit (learning need) regarding physiological changes, recovery period, self care and infant care
- Situational Low Self-esteem (R/T failure to complete normal labor and delivery)
- Any of the Self-care deficits R/T effects of anesthesia, decreased strength and endurance and/or physical discomfort
- Sleep Deprivation R/T hormonal or psychological responses, pain, fatigue of labor and delivery and/or demands of family
- In older books Doenges and Moorhouse include Family Coping: potential for growth R/T sufficiently meeting individual needs and adaptive tasks, enabling goals of self-actualization to surface AEB family member(s) moving in direction of health-promoting and enriching lifestyle
- Ineffective Role Performance R/T situational crisis (demands of new family member, changes in responsibilities of family members)
- Disturbed Body Image [some women don't handle having surgical scars very well!]
- Ineffective Sexuality Pattern R/T altered body structure or function
- (Risk for)Impaired Parenting
- Risk for Impaired Parent/Child Attachment
- Risk for injury (any of the postoperative complications that can occur, ie. anemia, tissue trauma, rubella sensitivity, Rh incompatibility, thrombophlebitis)
- Risk for Infection