NURSING CARE PLAN 1: Risk for Deficient Fluid Volume and Vaginal Bleeding (Postoperative Cesarean Section)

Assessment Nursing Background Goal and Objectives Nursing Interventions Evaluation

Diagnosis Knowledge

Postoperative Risk for Deficient Risk for deficient Fluid NOC: Hypovolemia and NIC: Hypovolemia and Severe GOALS MET
Cesarean Fluid Volume/risk for Severe Hemorrhage Hemorrhage Complication
Section Volume/Risk for Bleeding is a nursing Prevention Management After rendering the
Bleeding diagnosis possibly appropriate nursing
Maternal evidenced by 1. Immediate Postoperative interventions, goal was
complications restrictions of oral Short-Term Goal (Within Period (Within 0-24 hours): met as manifested by:
intake, blood loss; 24-48 hours):
pregnancy-related a. Monitor Vital Signs:  The client
complications. 1. Prevent Hypovolemia  Assess blood pressure, maintained
(NANDA) and Severe heart rate, and respiratory normotensive blood
Hemorrhage: rate every 4 hours or more pressure, stable vital
 The client will remain frequently if indicated. signs, and exhibited
normotensive, with  Notify the healthcare no evidence of
stable vital signs and provider promptly if any excessive bleeding
no evidence of vital signs deviate from within the specified
excessive bleeding the normal range. timeframe.
within 24-48 hours
post-Cesarean Section. b. Assess Uterine Contractions  The client
and Lochia: experienced no
Objectives:  Evaluate uterine delayed
 Monitor blood contractions and monitor complications,
pressure, heart rate, lochia every 2 hours to maintained
and respiratory rate detect any abnormalities. adequate fluid
every 4 hours.  Report excessive bleeding volume, and
 Assess uterine promptly and collaborate demonstrated
contractions and lochia with the healthcare team positive progress
every 2 hours. for further assessment. toward recovery
 Administer intravenous throughout the
(IV) fluids as c. Administer Intravenous (IV) postoperative
prescribed to maintain Fluids: period.
adequate hydration.  Initiate and maintain
 Evaluate the prescribed IV fluids to
postoperative incision prevent hypovolemia.
site and vaginal  Adjust fluid rate based on
bleeding regularly. ongoing assessments and
 Implement healthcare provider
postoperative bed rest recommendations.
to minimize physical
stress d. Evaluate Incision Site:

 Regularly inspect the

Long-Term Goal postoperative incision site
(Throughout for signs of bleeding,
Postoperative Period): infection, or dehiscence.
 Document findings
2. Prevent Delayed accurately and report any
Complications and concerns promptly.
Promote Optimal
Recovery: e. Implement Postoperative
 The client will Bed Rest:
experience no delayed  Instruct the client to
complications, adhere to prescribed bed
maintain adequate fluid
 volume, and rest to minimize physical
demonstrate positive stress and potential
progress toward exacerbation of bleeding.
recovery throughout  Assist with activities of
the postoperative daily living to prevent
period. unnecessary strain.

Objectives: 2. Ongoing Postoperative

 Continue monitoring Period (24 hours and beyond):
vital signs, uterine
contractions, and a. Continued Monitoring:
fluid balance  Regularly monitor vital
regularly. signs, uterine contractions,
 Educate the client on and fluid balance
signs and symptoms throughout the
of delayed postoperative period.
complications (e.g.,  Document any changes
infection, delayed and report to the
bleeding) and healthcare provider as
prompt reporting. needed.
 Collaborate with the
healthcare team to b. Education on Delayed
manage any Complications:
identified  Educate the client on signs
complications and symptoms of delayed
effectively. complications such as
 Provide emotional infection, delayed
support and address bleeding, or any unusual
any postoperative
 concerns. symptoms.
 Encourage  Instruct the client to report
adherence to any concerns promptly for
prescribed timely intervention.
medications, activity
restrictions, and c. Collaboration with
follow-up Healthcare Team:
appointments.  Communicate regularly
with the healthcare team
to discuss ongoing
assessments, address
complications, and modify
the care plan as needed.
 Participate in rounds and
interdisciplinary meetings
to ensure comprehensive
care.

d. Emotional Support:
 Provide ongoing
emotional support,
addressing any
postoperative concerns or
anxieties.
 Encourage open
communication and
actively listen to the
client's experiences and
 feelings.

e. Medication Adherence:
 Ensure the client adheres
to prescribed medications,
including analgesics and
prophylactic medications.
 Monitor for any
medication-related
adverse effects and report
to the healthcare provider.

f. Activity Restrictions:

 Reinforce adherence to
prescribed activity
restrictions to prevent
strain on the incision site
and potential bleeding.
 Provide guidance on safe
and comfortable
movements.

g. Follow-Up Appointments:
 Emphasize the importance
of attending follow-up
appointments with the
healthcare provider for
 ongoing assessments and
incision site checks.
 Assist in scheduling and
coordinating follow-up
care.

NURSING CARE PLAN 2: Cesarean Section Postoperative Wound Care

 Assessment Nursing Background Goal and Objectives Nursing Interventions Evaluation
Diagnosis Knowledge

The patient has Impaired Skin Impaired Skin/Tissue NOC: Wound Healing NIC: Wound Care GOALS MET
undergone a Integrity related Integrity is a NANDA
cesarean section, to surgical diagnosis that may be Short Term Goals: Within 1. Education on Wound After rendering the
and the focus is incision related to [untoward 1 Week of Nursing Care: appropriate nursing
on monitoring secondary to stretching or lacerations Interventions  Provide clear and concise interventions, goal was
and promoting cesarean section. of delicate tissues education to the client and met as manifested by:
healing of the (precipitous labor, 1. Promote Optimal their support system on
surgical incision. hypertonic contractile Healing proper wound care Short Term:
pattern, adolescence,  Objective: The client techniques, emphasizing  Absence of increased
large fetus), and will demonstrate the importance of redness, swelling, or
application of forceps]. early signs of healing, cleanliness, gentle signs of infection.
with decreased cleaning, and adherence to  Increased comfort,
redness and swelling the prescribed regimen. reported targeted pain
at the cesarean  Rationale: Empowering level.
section incision site. the client with knowledge  Demonstrated
fosters active participation understanding,
2. Manage Pain in their recovery and independent
Effectively reduces the risk of performance.
 Objective: The client complications.  Active monitoring,
will verbalize a pain noting improvements.
level of 4 or less on a 2. Demonstrate Wound  Improved mobility,
numeric pain scale, Cleaning Technique: increased ease of
indicating improved  Physically demonstrate the movement.
comfort and correct technique for  Consistent attendance
enhanced mobility. cleaning the cesarean of follow-up
section incision using
3. Ensure Proper sterile saline or prescribed appointments.
Wound Care solution.
Adherence  Rationale: Visual and Long Term:
 Objective: The client hands-on learning  Signs of complete
will independently enhances the client's healing observed.
perform proper understanding and  Restored mobility
wound care, confidence in performing without pain reported.
following the wound care  Active involvement,
prescribed regimen independently. positive changes in
and showcasing an scar appearance.
understanding of the 3. Provide Pain Management  Reports emotional
steps for optimal Strategies: well-being and
healing.  Collaborate with the confidence.
healthcare team to
implement effective pain
Long Term Goals: management strategies,
which may include
1. Achieve Complete administering prescribed
Wound Healing pain medications,
(Within 4-6 Weeks): suggesting positioning
 Objective: The techniques, and offering
client's cesarean relaxation methods.
section incision will  Rationale: Managing pain
exhibit complete promotes client comfort,
healing, with the facilitates mobility, and
absence of redness, encourages adherence to
swelling, or any signs postoperative care
of infection. recommendations.
2. Restore Full Mobility 4. Assist with Mobility and
and Comfort (Within Positioning:
6-8 Weeks):  Support the client in
 Objective: The client finding comfortable
will report full positions that do not strain
mobility without pain the incision site.
or discomfort, Encourage gradual and
indicating successful safe mobility, such as
recovery and walking short distances, to
restoration of normal prevent complications like
activities. atelectasis.
 Rationale: Promoting safe
3. Promote Scar mobility reduces the risk
Management and of postoperative
Aesthetics (Within 8- complications and
12 Weeks): supports overall recovery.
 Objective: The client
will actively engage 5. Monitor and Assess
in scar management Incision Site:
techniques, and the  Regularly assess the
cesarean section scar cesarean section incision
will show signs of site for signs of healing,
maturation and infection, or any
improved aesthetics. abnormalities. Document
findings consistently and
4. Ensure Emotional report any concerning
Well-being and observations to the
Confidence (Ongoing): healthcare provider.
 Objective: The client  Rationale: Early detection
will express of issues allows for
emotional well-being prompt intervention,
and confidence in the reducing the risk of
recovery process, complications and
addressing any promoting optimal wound
lingering concerns or healing.
anxieties related to
the cesarean section 6. Provide Emotional
experience. Support:
 Offer emotional support
by actively listening to the
client's concerns,
providing reassurance, and
addressing any anxieties
related to the cesarean
section experience and
recovery.
 Rationale: Emotional
well-being is integral to
the overall recovery
process and contributes to
a positive postoperative
experience.

7. Encourage Follow-Up
Appointments:
 Emphasize the importance
of attending scheduled
follow-up appointments
 with the healthcare
provider for incision
assessments and overall
recovery evaluation.
 Rationale: Regular
follow-up ensures ongoing
monitoring of the incision
site, allowing for timely
intervention if
complications arise.

8. Provide Information on
Scar Management:
 Educate the client on scar
management techniques,
including massage and
application of scar creams
or silicone sheets, to
promote optimal healing
and improve the aesthetics
of the cesarean section
scar.
 Rationale: Scar
management supports the
maturation of the scar and
may positively influence
its appearance.