- Deficient Fluid Volume related to Blood loss during Surgical procedure as evidenced by alteration in skin turgor and decreased vital parameters
- Deficient Knowledge related to inadequate knowledge of Cesarean delivery and Insufficient knowledge of postoperative needs as evidenced by Verbalization of concerns and Inquiries about what to expect with Cesarean delivery
- Impaired Tissue Integrity related to Surgical procedure and insufficient knowledge about maintaining tissue integrity as evidenced by Surgical incision and Prolonged incision pain
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Objective Data: -Hypotension -Bradycardia -Decreased venous filling -Decreased urine output -Dry mucous membranes -Dry skin -Weakness | Deficient Fluid Volume related to Blood loss during Surgical procedure as evidenced by alteration in skin turgor and decreased vital parameters | Patient will maintain blood pressure, heart rate, and body temperature within normal limits. Patient will display a urine output of 0.5 to 1.5 mL/kg/hr. | 1. Administer IV fluid replacement as indicated. Fluid replacement, including crystalloid solutions, is given to resolve fluid volume deficiency in C-section patients who are bleeding and dehydrated. 2. Encourage adequate fluid intake. While there is no specific time to restart an oral diet after a C-section, most women will be allowed ice chips and sips before resuming a light diet 8 hours later. 3. Administer medications as indicated. Oxytocin is routinely administered in patients after vaginal or C-section delivery to prevent postpartum hemorrhage and prevent possible fluid volume deficit complications. 4. Perform fundal massage as indicated. Fundal massage can help initiate uterine contractions that address uterine atony and help with the expulsion of retained placenta and clots. This action counteracts bleeding in patients who deliver vaginally or via C-section | Patient’s vital signs remained stable and/or returned to patient’s baseline. Patient’s intake and output stabilized. Patient’s lab values returned to baseline. Patient verbalized measures to take at home to maintain hydration/prevent dehydration. |
| Subjective Data: Verbalizes poor understanding Seeks additional information Denial of a need to learn Objective Data: Inaccurate demonstration or teach-back of instructions Inability to recall instructions Exhibiting aggression or irritability regarding teaching follow-up Poor adherence to recommended treatment or worsening medical condition Avoiding eye contact or remaining silent during teaching | Deficient Knowledge related to inadequate knowledge of Cesarean delivery and Insufficient knowledge of postoperative needs as evidenced by Verbalization of concerns and Inquiries about what to expect with Cesarean delivery | Patient will be able to verbalize understanding of expected body changes after C-section. Patient will be able to identify behavior and lifestyle modifications required during the recovery from C-section. | 1. Create a birth plan. Every pregnancy is unique, and every mother has different expectations for delivery. A birthing plan needs to be flexible, but assisting the mother in identifying her expectations will reduce stress and promote readiness. 2. Provide information through different resources. Some mothers might need information that is easier to understand or available in videos, while others prefer written leaflets or booklets. Provide verbal instructions using plain language. 3. Discuss post-op care. Provide education on pain control following surgery, monitoring and cleaning the incision, and not performing strenuous activities to allow for healing. Full recovery usually takes 4-6 weeks. 4. VBAC after C-section. Many women inquire about the ability to have a Vaginal Birth After Cesarean section (VBAC). This is a possibility as 60-80% of women do have vaginal births after a C-section. Educate the patient on their unique risk factors and considerations. | Patient identified risk factors of disease process and how to prevent worsening of symptoms. Patient participated in the learning process. Patient demonstrated the proper execution self-care skills such as wound care/insulin administration/blood pressure monitoring/etc. Patient identified barriers to their learning and recognize potential solutions to these barriers where possible. |
| Subjective Data: -Pain -Itching -Numbness to affected and surrounding skin Objective Data: -Changes to skin color (erythema, bruising, blanching) -Warmth to skin -Swelling to tissues -Observed open areas or breakdown, excoriation | Impaired Tissue Integrity related to Surgical procedure and insufficient knowledge about maintaining tissue integrity as evidenced by Surgical incision and Prolonged incision pain | Patient will perform appropriate wound care interventions to protect and heal surgical incisions. Patient will exhibit incision healing, including approximation without signs of infection | 1. Encourage proper wound care. The incision site must be cleaned as instructed to improve tissue integrity and promote proper wound healing. 2. Instruct the patient to avoid driving, lifting, or performing strenuous activities. Strenuous activities can add pressure on the abdomen and the surgical site and may cause complications like bleeding, wound dehiscence, and delayed healing. 3. Administer medications as indicated. Antibiotics and pain medications are indicated to help with pain control and infection prevention in patients who underwent C-section delivery. Pain that is not adequately controlled causes stress and disrupts the healing process. 4. Encourage ambulation. Ambulation promotes circulation, which promotes wound healing, improves tissue integrity at the incision site, reduces pain, and promotes timely recovery after C-section delivery. 5. Encourage the use of abdominal splints, especially during breastfeeding. Abdominal splints like pillows placed on the surgical site are encouraged to help deflect the infant’s weight from the suture line, lessen pain, and improve mobility. | Patient will maintain intact skin integrity. Patient will experience timely healing of wounds without complications. Patient will demonstrate effective wound care. Patient will verbalize proper prevention of pressure injuries. |