C Section Nursing Diagnosis and Nursing Care Plans

C Section Nursing Care Plans Diagnosis and Interventions

C Section NCLEX Review and Nursing Care Plans

A cesarean section, C-section, or Cesarean birth is a surgical method of delivery by making an incision in the mother’s abdomen and the uterus. It is used by healthcare professionals when they believe it is beneficial for the mother, the infant, or both.

The incision in the skin could be a:

1. Vertical Incision (Up and Down). This incision runs from the navel to the pubic hairline.

2. Horizontal Incision (Across from side to side). This incision runs throughout the pubic hairline. It is the most commonly used since it recovers well enough and causes minimal bleeding.

The incision utilized is determined by the mother’s and fetus’s health. The uterine incision might either be horizontal or vertical.

Furthermore, several women request cesarean birth for their first babies to prevent labor pain or the potential risks of natural birth or benefit from a planned delivery’s comfort. However, if the mother intends to have multiple children, this delivery is discouraged.

Women who have had several C-sections are more likely to suffer placental issues and excessive bleeding, which may necessitate complete removal of the uterus (hysterectomy).

If a scheduled C-section is being considered for the mother’s first delivery, she should consult with her health care practitioner to decide what is best for her and her baby.

Preoperative Assessment for C-Section

• Examine the patient for previous surgeries, subsequent illnesses, food or drug allergies, anesthetic reactions, and medications that could raise the risk of any surgical procedure.
• Before undergoing any operation, assess if the mother is in the maximum possible physical and psychological condition.
• Assess the patient’s weight. A patient who is obese and has poor nutritional health is at risk for a stagnant wound healing process. Also, they would additionally have trouble starting mobility and rotating after surgery since it increases her risk of pneumonia or thrombophlebitis.
• Tissue containing excess fatty cells would be challenging to suture, and the incision would heal significantly more slowly, putting the mother at risk of infection and tissue necrosis.
• Determine whether the patient is deficient in protein or vitamins, as they are required for new cell creation at the incision site and are associated with poorer healing.
• Determine whether the patient’s age still qualifies for Cesarean birth.
• Age can potentially increase the risk of surgery by impairing cardiovascular and hepatic function.
• Look into the patient’s comorbidities. A woman with secondary sickness is also more likely to experience surgery complications, depending on the severity of the disease, because the secondary illness may impair the woman’s capacity to adjust to the demands of the surgery.
• The patient’s general medication history must also be evaluated because some medicines may exacerbate the surgical risk by competing with the effectiveness of anesthesia.
• Assess the patient’s blood volume. A mother with a lower-than-normal blood volume may feel the consequences of surgery more intensely than a woman with an average blood volume.
• Intravenous fluid replacement is started preoperatively and postoperatively to prevent fluid and electrolyte imbalance.
• Explain to the patient how the cesarean birth will happen. Some women are pretty concerned about the treatment, and they want a very extensive description of the procedure before they can agree to the surgery without feeling terrified.
• Determine whether the patient has cardiovascular disease. A fearful patient is more likely to have a cardiac arrest after anesthetic administration.
• Acknowledge that the patient’s fear of C-section is reasonable to accept her sentiments as usual, which may boost her self-esteem.

Pre-operative Diagnostic Procedures for C-Section

Before undergoing surgery, the female patient must go through the diagnostic procedures advised by her doctor. Here are a few examples of diagnostic procedures:

• Circulatory, renal function, and fetal heart assessments
• Complete blood count, as well as PT and PTT – these are diagnostic methods for the circulatory system.
• Urinalysis – this diagnostic measure is required to determine renal function.
• Other diagnostic methods include vital sign determination, serum electrolyte, pH determination, blood typing and cross-matching, and ultrasound -these procedures determine fetal presentation and maturity.

Post-operative Management of C-Section

Below are some of the postoperative management procedures that the pregnant patient needs:

• Routine postoperative evaluation
• Vital signs, urine production, and vaginal bleeding are all monitored.
• Palpation of fundus postpartum
• If necessary, administer IV fluids; after that, progress to an oral diet as suitable; early feeding has been demonstrated to reduce hospitalization.
• Allow the patient to rate her pain using a pain rating scale. Some women may require patient-controlled analgesics or continual epidural injections to ease discomfort. On the other hand, supplemental analgesics with comfort measures include changing positions or arranging bed linen.
• If the patient intends to breastfeed, begin immediately after delivery. However, if the patient intends to bottle feed, she may use a tight brassier or breast binder in the postpartum period.
• Unless the patient has Long-Acting Reversible Contraception (LARC) inserted at the time of the procedure, discuss contraception along with abstaining from intercourse for 4-six weeks after cesarean birth.
• Instruct the mother to walk because it is the most effective way to relieve gas pain.
• Instruct the mother to use a pillow on her lap while feeding the newborn to divert the infant’s weight away from the suture line and reduce pain.
• Take special note of the patient’s first bowel movement following surgery, since if no bowel movement is noticed, the doctor may prescribe a stool softener, suppository, or enema to aid with stool discharge.
• If the patient has recovered well after surgery, she can be securely discharged 2 to 4 days later. The doctor will eliminate any staples used to approximate the skin prior to discharge. Moreover, if the patient has had a vertical skin incision or is at risk of poor healing due to diabetes or long-term steroid usage, the doctor may leave the staples in for an additional 2 to 3 days and have the patient come to the clinic at that time.

Nursing Diagnosis for C Section

C Section Nursing Care Plan 1

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to inadequate exposure, unawareness of the illness and information resources, and information misunderstanding secondary to C-section or cesarean birth as evidenced by confusion about narrative, improper behaviors, and insufficient comprehension of guidelines.

Desired Outcome: The client will articulate her awareness of the reasons for cesarean birth and postoperative expectations and will identify this as an alternate childbirth procedure in order to obtain the greatest possible outcome in the end.

C Section Nursing Care Plan 2

Acute Pain

Nursing Diagnosis: Acute Pain related to intensified muscle contractions, psychological responses, surgical injury, and distention of the bladder or abdomen related to C-section or cesarean birth as evidenced by reports of discomfort, protective or distracting behaviors, nervousness, sobbing, yelling, agitation, arrhythmia, and tachypnea.

Desired Outcome: The patient will verbally express diminished discomfort or pain, seem tranquil, be able to rest or sleep, and interact adequately.

C Section Nursing Care Plan 3

Powerlessness

Nursing Diagnosis: Powerlessness related to interpersonal communication, illness-related control, and helplessness lifestyle secondary to C-section or cesarean birth as evidenced by manifestations of helplessness in the face of adversity, lack of involvement in decisions about care regime and apathy.

Desired Outcome: The patient will convey specific wants and desires, anxieties, and vulnerability and contribute to decision-making wherever possible.

C Section Nursing Care Plan 4

Nursing Diagnosis: Anxiety related to actual or perceived harm to mother and fetal well-being, situational dilemma, a threat to one’s self-concept, and the emergence of complications secondary to C-section or cesarean birth as evidenced by wariness, despair, unworthy feelings, excessive tension, nervousness, sympathetic activation. and worries about the consequences.

Desired Outcome: The patient and her spouse will discuss their concerns, will appear relaxed and confident, will communicate concerns for the infant’s safety, and will finally exhibit lessened anxiety after discussing C section or cesarean birth.

C Section Nursing Care Plan 5

Risk for Ineffective Self Health Management

Nursing Diagnosis: Risk for Ineffective Self Health Management related to inadequate individual coping secondary to post-C-section procedure, a complicated therapeutic regimen, and conflicts with spiritual principles or cultural influences.

Desired Outcome: The patient will determine objectives for optimal health management related to post C-section. She will exhibit positive behaviors to adopt a therapy regimen into daily life, and express understanding of the treatment protocol.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.