Risk for Injury - NCP for Cesarean Section

Nursing Care Plan for Cesarean Section

Nursing Diagnosis : Risk for Injury related to biochemical function or regulation, the effects of anesthesia, tissue trauma.

Goal:

• Demonstrate behaviors to reduce risk factors and / or self-protection.
• Free from complications.

Itervention:

1. Review the prenatal and intra prenatal record, the factors of clients in complications.
Rationale: The presence of risk factors such as fatigue miometrial, excessive uterine distension, slow oxytocin stimulation, or thrombophlebitis a prenatal, allowing clients more susceptible to post-operative complications.

2. Monitor blood pressure, pulse and temperature. Note the skin is cold, wet, weak pulse and subtle, changes in behavior, delayed capillary refill, or cyanosis.
Rationale: High blood pressure can indicate the occurrence or continuation of hypertension. Hypotension and tachycardia may indicate dehydration and hypovolemia but may not occur until the circulating blood volume has been decreased to 35% - 50%, pyrexia may indicate infection.

3. Inspection bandage against excessive bleeding.
Rationale: Surgical wounds with drain, can dampen the bandage, but seepage is usually not visible and can indicate the occurrence of complications.

4. Note the catheter and amount of lochia flow and consistency of the fundus.
Rationale: The flow of lochia should not be much or contains clots. Fundus must remain contracted, firmly on the umbilicus. Protrusion of the uterus resulting in increased blood flow and loss.

5. Encourage exercise foot / ankle and early ambulation.
Rationale: Increased venous return, preventing ataxia / buildup on the lower extremities, lower the risk of phlebitis.

5. Inspection incision regularly, note the slowdown, or a change in healing.
Rationale: Excessive Stretching the incision, slowing the healing can cause clients tend to tissue separation and possible hemorrhage.

6. Replace lost fluids intravenously, according to the program.
Rationale: Average blood loss typically 600-800 ml, but prenatal physiological edema, increasing the need for replacement of large fluid volumes.

7. Monitor hemoglobin / hematocrit Post-surgery, compared with preoperative levels.
Rationale: Clients with a hematocrit of 33% or greater and an increase in the plasma with respect to pregnancy can tolerate the actual blood loss.

8. Increase the oxytocin infusion if uterine relaxation and / or heavy lochia.
Rationale: Stimulate miometrial contractility and decrease blood loss.

Acute Pain - Nursing Care Plan for Cesarean Section

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.