Nursing Care Plan Nursing care plan for a cardiac patient for CS

Time

Assessment 1-assess learning needs 2-assess stress level and whether procedure was planned or unplanned.

Nursing Diagnosis Knowledge deficit regarding surgical procedure, expectations and postoperative regimen related to lack of exposure or misinterpretation.

1-assess psychological response to event and availability of support system.

Anxiety related to situational crisis, threat to self-concept, perceived threat of maternal and fetal well-being.

Outcomes Verbalize understanding of indication for cesarean birth. Recognize this is an alternative childbirth method to obtain healthiest outcome possible. Verbalize fears for the safety of the client and the infant.

Nursing Intervention 1-Provide accurate information in simple terms, clarify misconceptions. 2-Encourge couple to ask questions and verbalize their understanding. 3-review indications necessitating alternative birth method. 4- Describe preoperative procedure in advance and provide rationale as appropriate. 5-provide postoperative teaching including demonstrating of leg exercises, coughing/deep breathing exercises. 6-discuss anticipate sensations during delivery and recovery period. 1-stay with the client, show empathy and caring. 2-reinforce positive aspects of maternal and fetal condition. 3-Encourge client/couple to verbalize and express feelings. 4-discuss past childbirth experience/expectations as appropriate. 5-provide period of privacy, if possible. Reduce environmental stimuli, such as the number of people present, as indicated by the clients desire. 1-eliminate anxiety-producing factors, provide accurate information, and encourage presence of partner. 2-instruct in relaxation techniques; position for comfort as possible. Use therapeutic touch, as appropriate. 3-administer sedative, narcotics, or preoperative medication as indicated. 1-review history for preexisting conditions/risk factors. 2-provide perineal care.

Evaluation

1-Assess location, nature and duration of pain, especially as it relates to the indication for CS.

Pain related to increased muscle contractions, psychological reactions.

Verbalize reduced discomfort/ pain.

2-assess for signs and symptoms of infection (elevated temperature , pulse, WBC,

Risk for infection related to invasive procedures, break in the skin and

Reduce risk of infection.

abnormal odor/color of vaginal discharge or fetal tachycardia)

exposure to pathogens.

3-cary out preoperative skin preparation. 4- Note Hb and Hct and estimated blood loss during CS. 5-Administer parenteral broad spectrum antibiotic. Display optimal FHR. 1-note presence of maternal factors that negatively affect placental circulation and fetal oxygenation. 2-continuw monitoring FHR, noting beat to beat changes and decelerations during and following contractions. 3-Note presence of variable decelerations; change client position from side to side. 4-monitor fetal heart response to preoperative medications or regional anesthesia. 5-provide supplemental oxygen to mother via mask. 6-administer IV fluid bolus prior to initiation of epidural anesthesia. 1-note length of labor, if applicable. 2- remove nail polish to detect circulation failure accurately. 3-monitor respiration, BP, pulse before, during and after administration of anesthesia. 4-place towel under the client hip. 5-note change in behavior or mental status, cyanosis of mucous membranes. 6-administer supplemental oxygen via mask as indicated. 7-Initiate IV infusion of electrolyte solution. 8-note alteration in vital signs, estimate and record blood losses. 9- prepare and administer oxytocin

Risk for impaired fetal gas exchange.

1-nassess for dehydration.

Risk for decreased cardiac output related to decreased venous return, alternation in systemic vascular resistance.

Remain normotensive with blood loss less than 800 ml.