CSection Delivery

CSection Delivery - CARE FOLLOWING CESAREAN BIRTH (4 HOURS...

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CARE FOLLOWING CESAREAN BIRTH (4 HOURS TO 3 DAYS POSTPARTUM) CLIENT ASSESSMENT DATA BASE Review prenatal and intraoperative record, and the indication(s) for cesarean delivery. Circulation Blood loss during surgical procedure approximately 600–800 ml Ego Integrity May display emotional lability, from excitation, to apprehension, anger, or withdrawal. Client/couple may have questions or misgivings about role in birth experience. May express inability to deal with current situation. Elimination Indwelling urinary catheter may be in place; urine clear amber. Bowel sounds absent, faint, or distinct. Food/Fluid Abdomen soft with no distension initially. Mouth may be dry. Neurosensory Impaired movement and sensation below level of spinal epidural anesthesia Pain/Discomfort May report discomfort from various sources, e.g., surgical trauma/incision, afterpains, bladder/abdominal distension, effects of anesthesia Respiratory Lung sounds clear and vesicular Safety Abdominal dressing may have scant staining or may be dry and intact. Parenteral line/saline lock when used, is patent, and site is free of erythema, swelling, and tenderness. Sexuality Fundus firmly contracted and located at the umbilicus. Lochia flow moderate and free of excessive/large clots. DIAGNOSTIC STUDIES CBC, Hb/Hct: Assesses changes from preoperative levels and evaluates effect of blood loss in surgery. Urinalysis (UA); Urine, Blood, Vaginal, and Lochial Cultures: Additional studies are based on individual need.
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NURSING PRIORITIES 1. Promote family unity and bonding. 2. Enhance comfort and general well-being. 3. Prevent/minimize postoperative complications. 4. Promote a positive emotional response to birth experience and parenting role. 5. Provide information regarding postpartal needs. DISCHARGE GOALS 1. Family bonding initiated 2. Pain/discomfort easing 3. Physical/psychological needs being met 4. Complications prevented/resolving 5. Positive self-appraisal regarding birth and parenting roles expressed 6. Postpartal care understood and plan in place to meet needs after discharge NURSING DIAGNOSIS: PARENT/INFANT ATTACHMENT, altered May Be Related To: Developmental transition/gain of a family member, situational crisis (e.g., surgical intervention, physical complications interfering with initial acquaintance/interaction, negative self-appraisal) Possibly Evidenced By: Hesitancy to hold/interact with infant, verbalization of concerns/difficulty coping with situation, not dealing with traumatic experience constructively DESIRED OUTCOMES/EVALUATION Hold infant, as maternal and neonatal conditions CRITERIA—CLIENT WILL: permit. Demonstrate appropriate attachment and bonding behaviors. Begin to actively engage in newborn care tasks, as appropriate. ACTIONS/INTERVENTIONS
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This note was uploaded on 10/06/2011 for the course NU 314 taught by Professor Rock during the Spring '11 term at North Alabama.

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CSection Delivery - CARE FOLLOWING CESAREAN BIRTH (4 HOURS...

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