Plan appropriate nursing care for each phases of Perioperative Phase.

(Pre-operative,
Intraoperative and Post-Operative Cesarean Delivery).

Assessment Nursing Expected Intervention Evaluation

Diagnosis Outcomes Nursing Rationale Resources
Interventions Required
Subjective: - Risk for - Achieve 1. Reinforce initial 1. Protects wound - Material - Goal Fully Met.
Impaired timely wound dressing and from mechanical Resources: After 1 hour of
(Patient Skin healing. change as injury and Visual Aids, effective nursing
reports) Integrity indicated. Use contamination. Materials and intervention, the
Pain, - Demonstrate strict aseptic Prevents Supplies patient was able
Itching, and behaviors/tech techniques. accumulation of needed for to: Demonstrate
Numbness niques to fluids that may demonstratio the proper
to affected promote 2. Gently remove cause excoriation. n. techniques of
and healing and to tape (in direction wound care and
surrounding prevent of hair growth) 2. Reduces risk of - Time and proper dressing.
skin. complications. and dressings skin trauma and effort on the
when changing. disruption of part of the - Goals partially
Objective: wound. nurse and met. After 2 days
- Changes 3. Apply skin patient. of effective
to skin color sealants or 3. Reduces nursing
(erythema, barriers before potential for skin intervention the
bruising, tape if needed. trauma and/or patient was able
blanching). Use hypoallergenic abrasions and to show
tape or provides improvement in
- Warmth to Montgomery additional wound healing as
skin. straps or elastic protection for evidenced by:
netting for delicate skin or
- Swelling to dressings requiring tissues.  Absence of
tissues. frequent changing. redness.
4. Can impair or  Absence of
- Observed 4. Check tension of occlude circulation itchiness.
open areas dressings. Apply to wound and to  Absence of
or tape at center of distal portion of Numbness
breakdown, incision to outer extremity. to affected
excoriation. margin of and
dressing. Avoid 5. Early surrounding
wrapping tape recognition of skin.
around extremity. delayed healing or
developing - Goal Fully Met.
5. Inspect wound complications may After a week of
regularly, noting prevent a more nursing
characteristics and serious situation. intervention
integrity. Note Wounds may heal client’s incision
patients at risk for more slowly in line is clean, dry,
delayed healing patients with and intact
(presence of comorbidity, or without
chronic the elderly in eryhthema.
obstructive whom reduced
pulmonary disease cardiac output
(COPD), anemia, decreases capillary
obesity or blood flow.
malnutrition, DM,
hematoma 6. Decreasing
formation, drainage suggests
vomiting, ETOH evolution of
(alcohol) healing process,
withdrawal; use of whereas
steroid therapy; continued
advanced age.) drainage or
presence of
6. Assess amounts bloody or
and characteristics odoriferous
of drainage. exudate suggests
 complications
7. Maintain (e.g., fistula
patency of formation,
drainage tubes; hemorrhage,
apply collection infection).
bag over drains
and incisions in 7. Facilitates
presence of approximation of
copious or caustic wound edges;
drainage. reduces risk of
infection and
8. Elevate chemical injury to
operative area as skin and tissues.
appropriate.
8. Promotes
9. Splint venous return and
abdominal and limits edema
chest incisions or formation. Note:
area with pillow or Elevation in
pad during presence of
coughing or venous
movement. insufficiency may
be detrimental.
10. Caution
patient not to 9. Equalizes
touch wound. pressure on the
wound,
11. Cleanse skin minimizing risk of
surface (if needed) dehiscence or
with diluted rupture.
hydrogen peroxide
solution, or 10. Prevents
running water and contamination of
mild soap after wound.
incision is sealed.
11. Reduces skin
12. Apply ice if contaminants; aids
appropriate. in removal of
drainage or
13. Use abdominal exudate.
binder if indicated.
12. Reduces
14. Irrigate edema formation
wound; assist with that may cause
debridement as undue pressure on
needed. incision during
initial
15. Monitor or postoperative
maintain period.
dressings:
hydrogel, vacuum 13. Provides
dressing. additional support
for high-risk
incisions (obese
patient).

14. Removes
infectious exudate
or necrotic tissue
to promote
healing.

15. May be used

to hasten healing
in large, draining
wound/ fistula, to
increase patient
comfort, and to
reduce frequency
of dressing
changes. Also
allows drainage to
be measured more
accurately and
analyzed for pH
and electrolyte
content as
appropriate.