Nursing Care Plan for Cesarean Section (C-section)

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Nursing Care Plan for Cesarean Section (C-section)

A Cesarean section (C-section) is surgery to deliver a baby. The baby is taken out through the mother's abdomen. In the United States, about one in four women have their babies this way. Most C-sections are done when unexpected problems happen during delivery. These include

• Health problems in the mother
• The position of the baby
• Not enough room for the baby to go through the vagina
• Signs of distress in the baby

C-sections are also more common among women carrying more than one baby.

The surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also takes longer to recover from a C-section than from vaginal birth. After healing, the incision may leave a weak spot in the wall of the uterus. This could cause problems with an attempted vaginal birth later. However, more than half of women who have a C-section can give vaginal birth later.


Nursing Assessment for Cesarean Section

Assessment is the systematic process of gathering, verification, and communication of client data (Potter & Perry, 2005).

The assessment results are found on the client by cesarean section on nursing care plan maternal / infant (Doenges & Moorhouse, 2001) namely:

1. Assessment of client data base
   Review the record of prenatal and intraoperative and indications for cesarean birth.


2. Circulation
   Blood loss during surgical procedures of approximately 600-800 ml.


3. Ego integrity
   Can show emotional labilitas of excitement to fear, anger or withdrawn. Client / partner may have questions or wrongly accept a role in the birth experience. Perhaps expressing inability to deal with new situations.


4. Elimination
   Urinary catheter may be inserted, clear urine and pale bowel sounds absent, vague or unclear.


5. Food / fluid
   Abdomen soft with no distension at baseline.


6. Neoro sensory
   Damage to the movement and sensation below the level of spinal epidural anesthesia.


7. Pain
   Discomfort may complain of a variety of sources such as surgical trauma, incision and accompanying pain, distended bladder-abdominal, the effects of anesthesia. The mouth may be dry.


8. Respiratory
   The sound is clear and vesicular lung.


9. Security
   Abdominal bandage may seem a little stain or dry and intact. Line parenteral, when used patent-free and hand erythema, swelling and tenderness.


10. Sexuality
    Fundus contractions stronger and located at the umbilicus. Lochea is free flow and excessive clot / lot.


11. Diagnostic tests
    Complete blood count, hemoglobin / hematocrit (Hb / Ht): assessing the change from preoperative levels and evaluate the effects of blood loss in surgery. Urinalysis: urine culture, blood, vaginal, and lochea.

Nursing Diagnosis for Cesarean section (C-section)

1. Acute pain related to postoperative wound

2. Risk for infection related to invasive procedures, skin damage, decrease in Hb

3. Risk for injury (mother) related to tissue trauma

4. Risk for impaired gas exchange (the fetus)

5. Deficient Knowledge : up to surgery

6. Anxiety

Nursing Diagnosis and Nursing Intervention for Cesarean Section Postoperative

Nursing Diagnosis

Risk for infection

Related to :

• bleeding,
• postoperative wound

Goal :
There were no infections, bleeding and wounds, after surgery.

Nursing Intervention for Cesarean Section Postoperative

1. Assess the condition of output / dischart out; number, color, and odor from the operation wound.
   R / recording the changes in output. The existence of a darker color with a bad smell may be a sign of infection.


2. Tell the client the importance of wound care during the postoperative period.
   R / Infection can arise from lack of cleanliness of the wound.


3. Have a general culture in the output.
   R / Various bacteria can be identified through the output.


4. Perform wound care.
   R / Incubation germs in the wound area can cause infection.


5. Tell the client how to identify signs of infection.
   R / Various clinical manifestations can be nonspecific sign of infection, fever and increased pain may be symptoms of infection.

Nursing Diagnosis

Acute Pain

Related to

• postoperative wound

Goal :
Pain is reduced / no pain

Nursing Intervention for Cesarean Section Postoperative

1. Assess the condition of pain experienced by the client.
   R / Measurement of the level of pain can be performed with pain scales.


2. Tell the client suffered pain and its causes.
   R / Improving coping clients, in dealing with pain.


3. Teach relaxation techniques.
   R / Reduced perception of pain.


4. Collaboration of analgesics.
   R / Reduced pain can be done by giving oral or systemic analgesics, in a broad spectrum / specific.

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