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.