Nursing Diagnosis for Cesarean Section : Acute pain related to surgical trauma, anesthesia, hormonal effects, distended bladder / abdomen.
Goal:
- Identify and use interventions to treat pain / discomfort appropriately.
- Reveal a reduction in pain.
- Relaxed able to sleep / rest.
Intervention:
1. Determine the characteristics and location of discomfort. Pay attention to verbal and non-verbal cues such as grimacing, stiffness, and limited movement or protect.
Rationale: The client may not be verbally reported pain and discomfort directly. Distinguish specific characteristics of pain and postoperative pain helps distinguish from complications.
2. Evaluation of blood pressure and pulse, note the change in behavior change.
Rationale: Pain can cause restlessness and increased blood pressure and pulse.
3. Change the position of the client, reduce harmful stimuli, and give a back rub. Encourage the use of breathing techniques, relaxation and distraction.
Rationale: muscle relaxes and distracts from the pain sensors.
4. Encourage early ambulation, Instruct to avoid gas-forming foods or liquids.
Rationale: Lower gas formation and increase the peristaltic to relieve discomfort due to gas accumulation.
5. Encourage the use of the left lateral recumbent position.
Rationale: Allows the gas increases from descending colon to the sigmoid, ease spending.
6. Palpate bladder, note the presence of the pain.
Rationale: Restore normal bladder function requires 4-7 days and overdistention of the bladder, creating a feeling of encouragement and discomfort.
7. Provide information for breastfeeding patients, the increased frequency of feeding, giving the exact position of the baby and mother's milk issued manually.
Rationale: This action can help the client lactation, stimulates milk flow and eliminates static and tension. Pillow helps support and protect the incision baby in a sitting position or tilted.
8. Encourage clients starting breastfeeding.
Rationale: The first strong sucking response and possible pain. Start breastfeeding may reduce pain and promote healing.
9. Collaboration of analgetic every 3-4 hours, continuing from the IV / intramuscular to the oral route. Give the drugs to clients who breastfeed 48-60 minutes before feeding.
Rationale: Improves comfort and correct the psychological status and improve mobility. Wise use of the drug, allowing the mother to enjoy the benefits of breastfeeding with no side effects in infants.