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Cesarean Section Postpartum Nursing Care Plan

Christopher Chie-For

C03375634

JMH

Submitted in partial fulfillment of the requirements in the course

Course NUR 318: Clinical Management of the Childbearing Family

Spring 2009
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Nursing Diagnosis: Risk for infection related to surgical incisions made during Cesarean section
Assessment data
Subjective Data:
Age:
Gravida:
Para: (term, preterm,
abortion, living children)
Obstetrical History:
overview of previous
pregnancy outcomes; dates
of deliveries, length of
pregnancies, induction of
labor or spontaneous labor,
weight of babies, sex of
babies, and complications
before, during, and after
delivery
Planning and Implementation Phase
Goals Interventions
Long term:
1. The patient will 1. The nurse will assess the
remain free from patient for any signs of
symptoms of infection such as redness,
infection until warmth, or discharge at
discharge. the surgical site, and
increased body
temperature during
every shift.
2. The nurse will report any
changes in WBC count
and/or pathogenic
growth on culture
3. The nurse carefully wash
and pat dry skin,
including skinfold areas.
Use hydration and
moisturization on all at-
Rationale
(Cite References)
1. Nursing interventions help
prevent and ensure early
detection of infection in a
client at risk, such as a
postoperative patient (Perry
& Potter, 2009, pp. 653).
2. The white blood cell count
and the automated absolute
neutrophil count are better
diagnostic tests for adults
and most children
(Cornbleet, 2002).
3. Atopic dermatitis is a
common, chronic skin
condition that can be
managed in most clients by
prescribing avoidance
Evaluation
Goals met/partially met
Or unmet
1. LTG will either be met, partially
met, or not met; goals would be
met if patient/nurse successfully
completed all the interventions
previously mentioned, and if the
patient/nurse also met the LTG;
patient would be marked as
partially met if they met some of
the interventions and the LTG;
patient would be evaluated as
unmet if the patient/nurse did not
complete any of the interventions
or the LTG
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Gynecological History: onset
of menarche; previous
gynecological surgeries and
conditions;
illnesses/diseases affecting
reproductive organs and
function; abnormal Pap
smears, mammograms, and
other gynecological tests
Prenatal/Past Medical
History:
Current or past
illnesses/diseases; hospital
admissions; past
surgeries/procedures
Surgical History:
Previous surgeries
Family History:
Family history of
medical/gynecological
conditions and malignancies
Labor and Delivery:
Date and time?
risk surfaces
1. The nurse will teach the
Short Term:
patient to wash hands often,
1. The patient will
especially after toileting,
learn/demonstrate
before meals, and before and
appropriate hygienic
after administering self-care.
measures such as hand
washing, oral care, 2. The nurse will teach the
perineal care, and will patient that the skin is an
also understand other important protective barrier
methods for preventing and how to assess the skin
infection. for infection.
3. The nurse will explore
with the patient potential
etiological factors which
potentiate infection and
include appropriate health
teaching
4. The nurse will encourage
adequate fluid intake.
5. The nurse will recommend
responsible use of antibiotics;
measures, good skin care,
antihistamines, and
conservative topical
medications (Mack, 2004).
1. Hygienic care is important to
prevent infection in at-risk 1. STG will either be met, partially
patients, such as postoperative met, or not met; goals would be
(Wujcik, 1993). met if patient/nurse successfully
completed all the interventions
2. The major route of
previously mentioned, and if the
transmission for pathogens
patient/nurse also met the STG;
identified in the health care
patient would be marked as
setting is unwashed hands (CDC,
partially met if they met some of
2002b).
the interventions and the STG;
3. Fluid intake helps thin patient would be evaluated as
unmet if the patient/nurse did not
secretions and replace fluid lost
complete any of the interventions
during fever (Calianno, 1999).
or the STG
4. Widespread use of certain
antibiotics, particularly third-
generation cephalosporins, has
been shown to foster
development of generalized
beta-lactam resistance in
previously susceptible bacterial
populations (Yates, 1999).
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Cultural History: use antibiotics sparingly. 5. Protein-energy malnutrition is

Cultural considerations to associated with a significant
take into account 6. When the client is decrease in immunity (Ritz &
malnourished, the nurse will Gardner, 2006)
Allergies: watch carefully for signs of
infection and maintain every
Food and drug allergies
action possible to protect the
client from infection.
Medications:
Prescribed medications
(probably opioid analgesic),
OTC drugs, herbals, and
recreational drugs
2. The patient will
1. Systemic infections tend to
demonstrate an 1. The nurse will make sure
Alcohol/smoking use? cause more generalized systems
understanding of that the client will report
and research has shown that 1. STG will either be met, partially
symptoms of infection onset of a fever, a cough,
Any concerns, questions, fever tends to be the first sign of met, or not met; goals would be
to be aware and report cloudy or foul smelling urine,
and/or discomforts an infection (NCCN, 2006). met if patient/nurse successfully
any symptoms of new onset sore throat or
completed all the interventions
infection to the nurse tightness in chest, or new
Objective Data: previously mentioned, and if the
by July 15, 2008. onset pain at the surgical
Temp: patient/nurse also met the STG;
site, catheter site, or IV site
BP: patient would be marked as
to the nurse.
HR: partially met if they met some of
RR: the interventions and the STG;
patient would be evaluated as
Lab Data: CBC, BMP, ABG, unmet if the patient/nurse did not
PT/aPTT, etc. complete any of the interventions
or the STG
Physical Assessment:
A full head-to-toe
assessment with special
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focus on signs of abnormal

bleeding and assessment of
surgical incisions of C-
section

Additional Nursing Diagnoses:

1. Impaired physical mobility related to abdominal surgical incisions

2. Disturbed body image related to abdominal surgical incisions

3. Deficient knowledge related to signs of infection and methods to prevent infection

4. Acute pain related to large, abdominal surgical incision