Last updated on May 16th, 2022 at 07:30 am
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
A nursing examination of a pregnant woman preparing to have a cesarean birth is also necessary to acquire a health history that will be needed later. Here are some of the preoperative assessments that must be completed:
- 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.
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
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 Interventions||Rationale|
|Provide accurate information in simple terms and clear up any misconceptions about C-section.||The patient’s capacity to grasp the information needed to stress the circumstance can hamper informed judgments about cesarean birth. If they do not comprehend the terms, they may not process the new knowledge.|
|Encourage the couple to ask questions and express their thoughts on the C-section.||This intervention allows the nurse to assess and evaluate the patient’s or couple’s knowledge of C-sections. As a result, this approach will address all of the couple’s specific inquiries and fill up any knowledge gaps as needed. Thus, check that all of the information provided is correct.|
|Examine the conditions that require alternate birth procedures.||Cesarean birth should be considered an option rather than an unusual situation to improve mother and fetal safety and well-being.|
|Discuss preoperative procedures to the patient ahead of time and provide reasons as needed.||It is critical to explain why a particular choice was made in preparation for the procedure. The nurse should thoroughly describe immediate preoperative treatments, such as surgical skin preparation, fasting before surgery, pre-medications, and mode of transportation to surgery.|
|Examine the patient’s need for postoperative measures. Educate the patient on the importance of postoperative measures such as an indwelling urinary catheter, IV fluid delivery, and the implantation of an epidural catheter for post-procedure pain relief (if preferred by the client). Understanding the reasons behind the methods may give the patient a sense of control over her circumstances.|
|Explain to patients the complications that may occur during the delivery and recuperation period.||Knowing what might happen helps to avoid unneeded concerns. Preoperative teaching aims to familiarize the client with the cesarean operation and any unique equipment that will be needed.|
|Preoperative education and postoperative reinforcement learning should include leg movements, correct coughing, deep breathing exercises, incentive spirometry, splinting, and abdominal relaxing activities.||This approach prevents deep venous thrombosis and hypostatic pneumonia complications and reduces stress on the surgical site. Abdominal tightness also alleviates the discomfort caused by gas production and abdominal distension. Moreover, deep breathing exercises performed regularly fully oxygenate the lungs and prevent lung secretion blockage. Preoperative education can also minimize the patient’s concerns about cesarean birth, and they are more likely to understand what is taught.|
|Discuss and create a postoperative pain management strategy, and go over how to utilize the pain scale.||Creating a pain management strategy with the patient increases the probability of pain control effectiveness. Some patients may believe that a cesarean birth will be less painful than a vaginal birth, or they may be afraid of becoming dependent on opioids.|
C Section Nursing Care Plan 2
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 Interventions||Rationale|
|Every time a patient complains of pain, conduct a pain assessment.||Developments from earlier reports should be noted, compared, and investigated to determine labor progress or rule out any worsening of the patient’s case or the severity of the condition. Always use a rating scale to assess the client’s pain and identify its attributes (frequency, duration, severity, intervals).|
|Observe the patient’s vital signs regularly.||Keep an eye out for arrhythmia, high blood pressure, and accelerated respiration. Alteration in these vital signs is frequently associated with severe pain and distress.|
|Avoid situations that cause anxiety (e.g., loss of control) and encourage the spouse’s involvement.||A variety of things alters individual pain tolerance levels. Severe anxiety during an emergency can cause discomfort due to stress, tension, and pain, impairing the patient’s capacity to manage. Presenting the patient with social and professional assistance offers support and reassurance while reducing discomfort.|
|Motivate the patient to articulate her suffering feelings verbally.||Allow the patient to express her pain perceptions and acknowledge her suffering experienced in a cesarean birth. Others cannot feel pain since it is a subjective sensation. Demonstrate acceptance of the patient’s pain response.|
|Examine the patient’s understanding and expectations about pain management and previous pain experiences and strategies used.||Antenatal delivery preparation improves maternal contentment and may lower pain levels. Antenatal education is crucial for getting patient agreement; the goal is to provide helpful information to assist mothers in developing reasonable expectations about pain control during labor.|
|Instruct and promote effective relaxation techniques.||Utilize alternative therapies as needed. Deep breathing techniques, music education, massages, and other relaxation treatments can help ease anxiety and stress, increase comfort, and boost a sense of well-being. Excessive anxiety and worry enhance catecholamine production, such as adrenaline, intensify painkiller impulses, stimulate pain perception in the cerebral cortex, and diminish pain threshold.|
|Encourage proper rest periods following cesarean delivery.||Following a C-section is spent recovering from surgery and adjusting to parenthood. Before taking on the mother’s new position, the patient must rest well to avoid weariness and recover properly. Mothers may appreciate early discharge because it allows the family, including older siblings, to spend time together at home. It also provides the woman with enough moral and social assistance.|
|Discuss with family members how to help the patient and decrease the pain caused by cesarean birth.||Family emotional and psychological support can aid in healing and lessen postnatal discomfort.|
|Sedatives, narcotics, or preoperative medications should be administered as prescribed.||By inhibiting pain impulses, it promotes comfort. Thus, anesthetic agents’ activity is augmented. Following a cesarean birth, most women feel discomfort and require opiate analgesia; roughly 20% of women who have a cesarean birth endure serious complications of postoperative pain. Personalized or diversified post-discharge opioid prescribing methods have been proven to prevent unnecessary opioid analgesic prescription and use, and they should be implemented regularly.|
C Section Nursing Care Plan 3
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 Interventions||Rationale|
|Encourage the patient to evaluate options in the care regimen when applicable, such as IV placement, and anesthetic selection.||Allow the patient to manage as many events as possible, such as food selection, IV cannula installation, and anesthetic type selection, since care limits may allow the patient to have some sense of control over the circumstances.|
|Acknowledge the patient’s or couple’s expectations and objectives for the cesarean birth procedure.||This intervention allows for the accommodation of demands and promotes a pleasant outcome. Raising knowledge and preparedness for labor is crucial for overcoming birthing anxiety. Well-prepared women have more assurance, which translates to less fear of ruining control over the situation.|
|Allow the couple to have personal time and space before the C-section, if possible. If the partner is not available, the nurse may stay with the patient.||Allow the soon-to-be parents to express their feelings regarding the C-section in their way. Leaving the patient alone might cause feelings of hopelessness and increase anxiety. Giving the mother constant emotional and psychological assistance promotes a safe and nurturing environment while reducing fear and suffering.|
|Provide information and discuss the patient’s or couple’s perspectives regarding cesarean birth.||The provision of information alleviates the stress caused by misunderstandings and excessive fear. Women who are well-prepared for pregnancy and delivery have higher expectations of massive pain levels and are less likely to encounter incapacity and lack of control.|
|Create a treatment plan with the patient that includes agreed-upon goals.||This approach increases commitment to the goal while also maximizing outcomes. Shared decision-making before and throughout pregnancy and delivery is crucial for creating and maintaining a rapport with patients marked by respect, mutual understanding, multidirectional interaction, and shared control or power.|
|Facilitate the patient’s return to a productive career in whatever capacity is feasible.||The extent of recuperation after a cesarean birth varies by patient. Emotional recovery might be significantly more difficult for some women than physical recovery. Difficulties with newborn care, especially breastfeeding, impact the patient’s productive function. The patient’s physical and emotional recovery can be aided by providing support and social engagement. Education about newborn care and nursing gives the patient more control over the circumstance and her new role as a mother.|
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 Interventions||Rationale|
|Determine whether or not a C-section is planned.||If the surgery is unanticipated, the patient or couple usually has little time to prepare psychologically or emotionally. Even if planned, cesarean birth can cause anxiety owing to the apparent physical harm to the mother and newborn.|
|Take note of and acknowledge the patient’s expressions of dread, despair, or powerlessness.||Validation assists both the nurse and the patient deal with fear in a realistic manner. Fears of relinquishing power, complications, death or harm to oneself or the baby, spinal anesthesia, episiotomies, perineal tearing, and uncertainty about C-section must be explained to the patient.|
|Maintain effective communication with the patient. Speak slowly and emphatically.||Therapeutic conversation reduces social transmission anxiety and demonstrates concern for the patient or couple. According to research, nurse companionship with the patient minimizes maternal distress during and after a C-section.|
|Allow the patient or couple to express their inner thoughts and emotions about having a cesarean birth.||This intervention assists in distinguishing between negative sentiments and worries and provides an opportunity to deal with ambiguous or unsettled grieving sensations. The patient may also feel intense intimidation to her self-esteem due to her emotions of inadequacy, weakness as a woman, and failure to meet her expectations. The partner may doubt their ability to assist the patient and provide sufficient assistance.|
|As necessary, allow the patient to share and elaborate on previous delivery experiences or expectations.||The patient’s fear may be heightened by distorted memories of previous deliveries or false perceptions of the peculiarity of cesarean birth.|
|Allow the patient to have some alone time.||This approach allows the patient or couple to assimilate information properly, arrange resources, and adapt.|
|Assist the patient with preoperative nursing management.||Preoperative nursing management familiarization can dramatically reduce anxiety, heart rate, breathing rate, and blood pressure.|
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.
|C Section Nursing Interventions||Rationale|
|Give the patient information regarding postnatal care after a cesarean birth.||Information on postpartum care and how to deal with potential difficulties can help ease stress and put apparent “chaos” into context. An unanticipated, emergent cesarean delivery can be highly traumatic, with unusual and invasive procedures taking place in quick succession, affecting the mother’s ability to process the situation. The information helps mothers prepare for a new life, reduces maternal mortality during this time, and supports recovery.|
|Create a self-monitoring plan with the patient.||Data relevant to the patient’s case should be shared, such as test findings or blood pressure measurements. This intervention gives the patient a sense of control and allows them to track their progress and make educated decisions.|
|Give positive reinforcement for the patient’s efforts.||Positive reinforcement fosters the persistence of desired behavior. Maintain an optimistic attitude toward the patient’s talents and possibility for progress by emphasizing positive attributes of the circumstance. Helping the patient embrace herself and her distinct qualities will foster growth and improve her self-care skills.|
|Examine the patient’s surroundings for elements that may be generating sensory overload.||Cesarean birth can be exhausting for the patient, and she may lose focus on the operations being conducted. Determine which elements are under the nurse’s control and which are not.|
|Evaluate the patient’s ability to move in bed and breastfeed.||Explain why getting up in the morning and caring for the newborn are essential. Early ambulation aids in the prevention of deep vein thrombosis, and early nursing aids in establishing appropriate milk production.|
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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
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