Nursing Care Plan For Cesarean Section

Nursing Diagnosis Impaired Skin/Tissue Integrity related to mechanical trauma of surgical removal of skin and subcutaneou s tissue secondary to Cesarean section

Backgrou nd Study Skin is the body’s first line of defense against foreign materials that can be considered as injuring agents. Once the skin is disrupted, this will put Assessment a person at Subjective: risk since it “Mayda ak may samad kay become a gin Cesarean good ak paganak,” medium for verbalized by bacterial the client. growth. Objective: Cesarean Destruction section, of skin layers like any Desruption of other tissue layers. surgical (+)Redness procedures on the , includes incision site. invasion of (+)Swelling the inside on the body, incision site specifically

INFEREN CE Emergenc y CS

Abdomina l incision and Uterine incision

Alteration s of the Skin

Goals and Objectives GOAL: After 3 days of nursing interventions, the patient will be able to display timely healing of skin lesions/ wounds without complication. OBJECTIVES: After 8 hours of nursing interventions, the patient will be able to: • Participate in prevention measures and treatment program • Maintain physical well-being. • Ability to manage situation.

Interventions

Rationale

Independent Establish rapport Perform bedside care

Inspect skin daily basis obseve changes unusualities

To gain trust with the client To enhance patient’s self esteem and to provide comfort to the patient

on and for To determine and unusual ties and report it to physician for prompt treatment. Keep the area clean, carefully This will assist dress wound, support incison, body’s natural prevent infection process of

Evaluation Goal met as evidenced by the patient has able to display timely healing of skin lesions/ wounds without complication .

the skin and subcutaneo us area. (NANDA 9th edition.pp 461-465) (MedSurgical Nursing, Black and Hawks 8th Edition pp 952-954)

repair Encourage client to demonstrate good skin hygiene, e.g., wash thoroughly and pat dry carefully after teaching.

DEPENDENT Medication such as antibiotics COLLABORATIV E Provide optimum nutrition such as increased protein intake.

Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin To prevent post operative wound complication To provide a positive nitrogen balance to aid in healing. (NANDA 9th edition pp 461-465) (Med-Surgical Nursing, Black and Hawks 8th

Edition pp 952-954)

Nursing Diagnosi s Acute pain related to abdomina l incision secondary to surgery. Subjecti ve cues: “Masakit pa an tinahian han han ak tiyan nan nakukuria n ak pagkiwa” as

Backgroun d Study

INFERENC E

Pain is Emergency CS defined as unpleasant sensory Abdominal and and uterine emotional incision experience arising Tissue from actual trauma or potential tissue damage or described Prostagland in terms of in release+ Uterine such Contraction damage. + Loss of (Internation Anesthetic al Effect Association for the

Goals and Objectives GOAL: At the end of my nursing intervention of 8 hours duty, the patient will be able to report pain is relieved or controlled. OBJECTIVES: By the of 1hour of my nursing intervention, the client will: •

Report pain intensity from 4 to 6 will decrease at

Interventions

Rationale

Independent Establish rapport to the patient

Monitor Vital signs

Perform bedside care

To easily gain cooperation form the patient To have baseline data and for comparison for future data To enhance patient’s self esteem and to provide comfort to

Evaluatio n Goal met as evidenced by the patient has able to manage pain relieve and controlled from 4to 6 to 2-3 on the pain rating scale.

verbalized by the patient. Objectiv e cues: Temp: 38.4 °C PR: 88 bpm RR: 24 cpm BP: 130/90 mm Hg Rated pain as 4 to 6 out of 0 to 10 pain scale. Pain increa ses when moves vigoro usly Incision site:

Study Pain);

(Nurse’s Pocket Guide)

of

2 to 3 from 0 to 10 pain scale.

Sensation of Pain •

Participate in demonstrati ng techniques to relieve pain

•

Have ability to manage situation.

Elevated Vital Signs

the patient Observe and document location, severity and character of pain.

Promote bedrest, allowing patient to assume position of comfort Control environment temperature

By getting the following information, we are asssitting in differentiating cause of pain and providing information about disease progression/resoluti on, development of complications and effective interventions. Bedrest in lowfowler’s posiiton reduces intraabdominal pressure.

Cool surrounding aids in minimizing Employ non dermal discomfort. pharmacologic pain distraction To prevent such as: Music therapy, dependecy on medication for pain Imagery,etc DEPENDENT Medication such as

Wound: dry, no discharge s noted Dressing and plaster were clean and fully covered the incision site No foul odor noted on the site.

NSAID’s

Relieves pain immediately. (NANDA 9th edition pp 461-465)