NURSEREVIEW.

ORG 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.

Circu !"i#$
Blood loss during surgical procedure approximately 600 00 ml

E%# I$"&%ri"'
!ay display emotional la"ility, from excitation, to apprehension, anger, or withdrawal. #lient$couple may have %uestions or misgivings a"out role in "irth experience. !ay express ina"ility to deal with current situation.

E i(i$!"i#$
&ndwelling urinary catheter may "e in place' urine clear am"er. Bowel sounds a"sent, faint, or distinct.

F##)*F ui)
("domen soft with no distension initially. !outh may "e dry.

N&ur#+&$+#r'
&mpaired movement and sensation "elow level of spinal epidural anesthesia

P!i$*Di+c#(,#r"
!ay report discomfort from various sources, e.g., surgical trauma$incision, afterpains, "ladder$a"dominal distension, effects of anesthesia

R&+-ir!"#r'
)ung sounds clear and vesicular

S!,&"'
("dominal dressing may have scant staining or may "e dry and intact. *arenteral line$saline loc+ when used, is patent, and site is free of erythema, swelling, and tenderness.

S&.u! i"'
,undus firmly contracted and located at the um"ilicus. )ochia flow moderate and free of excessive$large clots.

DIAGNOSTIC STUDIES
CBC/ H0*Hc"1 (ssesses changes from preoperative levels and evaluates effect of "lood loss in surgery.

Uri$! '+i+ (UA)2 Uri$&/ B ##)/ V!%i$! / !$) L#c3i! Cu "ur&+1 (dditional studies are "ased on individual need.

NURSING PRIORITIES
-. .. 1. 3. 4. *romote family unity and "onding. /nhance comfort and general well0"eing. *revent$minimi2e postoperative complications. *romote a positive emotional response to "irth experience and parenting role. *rovide information regarding postpartal needs.

DISCHARGE GOALS
-. .. 1. 3. 4. 6. ,amily "onding initiated *ain$discomfort easing *hysical$psychological needs "eing met #omplications prevented$resolving *ositive self0appraisal regarding "irth and parenting roles expressed *ostpartal care understood and plan in place to meet needs after discharge

NURSING DIAGNOSIS1 M!' B& R& !"&) T#1

PARENT*INFANT ATTACHMENT/ ! "&r&) 5evelopmental transition$gain of a family mem"er, situational crisis (e.g., surgical intervention, physical complications interfering with initial ac%uaintance$interaction, negative self0appraisal) 6esitancy to hold$interact with infant, ver"ali2ation of concerns$difficulty coping with situation, not dealing with traumatic experience constructively 6old infant, as maternal and neonatal conditions permit. 5emonstrate appropriate attachment and "onding "ehaviors. Begin to actively engage in new"orn care tas+s, as appropriate.

P#++i0 ' E4i)&$c&) B'1

DESIRED OUTCOMES*EVALUATION CRITERIA5CLIENT WILL1

ACTIONS*INTERVENTIONS I$)&-&$)&$"

RATIONALE

/ncourage client to hold, touch, and examine the infant, depending on condition of client and the new"orn. (ssist as needed.

7he first hours after "irth offer a uni%ue opportunity for family "onding to occur "ecause "oth mother and infant are emotionally receptive to cues from each other, which initiate the attachment and ac%uaintance process. (ssistance in first few interactions or until &8 line is removed helps client avoid feelings of discouragement or inade%uacy. 9ote: /ven if client has chosen to relin%uish her child, interacting with the new"orn may facilitate the grieving process. 6elps facilitate "onding$attachment "etween father and infant. *rovides a resource for the mother, validating the reality of the situation and the new"orn at a time when procedures and her physical needs may limit her a"ility to interact. /ye0to0eye contact, use of en face position, tal+ing in a high0pitched voice, and holding infant closely are associated with attachment in (merican culture. ;n first contact with the infant, a mother manifests a progressive pattern of "ehaviors, where"y she initially uses fingertips to explore the infant<s extremities and progresses to using the palm "efore enfolding the infant with her whole hand and arms. 6elps client$couple understand significance and importance of the process and provides reassurance that differences are to "e expected. 7he arrival of a new family mem"er, even when wanted and anticipated, creates a transient period of dise%uili"rium, re%uiring incorporation of the new child into the existing family. =nresolved conflicts during the early parent0infant ac%uaintance process may have long0term negative effects on the future parent0child relationship. *arents need to wor+ through meaning attri"uted to stressful events surrounding child"irth and orient themselves to reality "efore they can focus on infant. /ffects of anesthesia, anxiety, and pain can alter the client<s perceptual a"ilities during and following surgical intervention. /arly contact has a positive effect on duration of "reastfeedings' s+in0to0s+in contact and initiation of maternal tas+s promotes "onding. >ome cultures (e.g., 6ispanic, 9ava?o, ,ilipino, 8ietnamese) may refrain from "reastfeeding until the mil+ flow is esta"lished. *romotes family unity, and helps si"lings "egin process of positive adaptation to new roles and incorporation of new mem"er into family structure. 6elps couple to process and evaluate necessary information, especially if initial ac%uaintance period has "een delayed.

*rovide opportunity for father$partner to touch and hold infant and assist with infant care as allowed "y situation.

;"serve and record family0infant interactions, noting "ehaviors indicative of "onding and attachment within specific culture.

5iscuss need for usual progression and interactive nature of "onding. Reinforce normalcy of variation of response from one time to another and among different children. 9ote ver"ali2ations$"ehaviors suggesting disappointment or lac+ of interest$attachment.

(llow parents the opportunity to ver"ali2e negative feelings a"out themselves and the infant. 9ote circumstances surrounding cesarean "irth, parents< self0appraisal and perception of "irth experience, their initial reaction to infant, and their participation in "irth experience.

/ncourage and assist with "reastfeeding, dependent on client<s choice and cultural "eliefs$practices.

@elcome family and si"lings for "rief visit as soon as maternal$new"orn condition permits. (Refer to #*: 7he #lient at 3 6ours to . 5ays *ostpartum' 95: ,amily #oping: potential for growth.) *rovide information, as desired, a"out infant<s safety and condition. >upport couple as needed.

&nitiate contact "etween client$couple and infant as soon as possi"le. &f infant is sent to neonatal intensive care unit, esta"lish line of communication "etween nursery staff and client$couple. 7a+e pictures of neonate and allow for visits when client<s physical status permits. (Refer to #*: 7he *arents of a #hild with >pecial 9eeds.) (nswer client<s %uestions regarding protocol of care during early postdelivery period.

Reduces anxiety that may "e associated with handling infant, fear of un+nown, and$or assuming the worst regarding infant status.

&nformation relieves anxiety that may interfere with "onding or result in self0a"sorption rather than inattention to new"orn.

C# !0#r!"i4&
9otify appropriate healthcare team mem"ers (e.g., nursery staff or postpartal nurse) of o"servations as indicated. &nade%uate "onding "ehaviors or poor interaction "etween client$couple and infant necessitates support and further evaluation. 9ote: &n some cultures, e.g., 9ative (merican, the father may practice a period of ritual avoidance "eginning immediately after the "irth. (Refer to #*: 7he #lient at 3 6ours to . 5ays *ostpartum' 95: *arenting, ris+ for altered.) !any couples have unresolved conflicts regarding initial parent0infant ac%uaintance process that may re%uire resolution after discharge.

*repare for ongoing support$follow0up after discharge, e.g., visiting nurse services, community agencies, and parent support group.

NURSING DIAGNOSIS1 M!' B& R& !"&) T#1 P#++i0 ' E4i)&$c&) B'1

PAIN 6!cu"&7*6DISCOMFORT7 >urgical trauma, effects of anesthesia, hormonal effects, "ladder$a"dominal distension Reports of incisional pain, cramping (afterpains), headache, a"dominal "loating, "reast tenderness' guarding$distraction "ehaviors, facial mas+ of pain &dentify and use appropriate interventions to manage pain$discomfort. 8er"ali2e lessening of level of pain. (ppear relaxed, a"le to sleep$rest appropriately.

DESIRED OUTCOMES*EVALUATION CRITERIA5CLIENT WILL1

ACTIONS*INTERVENTIONS I$)&-&$)&$"
5etermine characteristics and location of discomfort. Rate severity on a 0-0 scale. 9ote ver"al and nonver"al cues, such as grimacing, rigidity, and guarding or restricted movement.

RATIONALE

#lient may not ver"ally report pain and discomfort directly. #omparing specific characteristics of pain aids in differentiating postoperative pain from developing complications (e.g., ileus, "ladder retention or infection, wound dehiscence).

*rovide information and anticipatory guidance regarding causes of discomfort and appropriate interventions. /valuate B*, pulse, and "ehavior changes (e.g., distinguish "etween restlessness associated with excessive "lood loss from that resulting from pain). 9ote uterine tenderness and presence$ characteristics of afterpains' postoperative infusion of oxytocin.

*romotes pro"lem solving, helps reduce pain associated with anxiety and fear of the un+nown, and provides sense of control. &n many clients pain may cause restlessness and an increase in B* and pulse. (dministration of analgesics may lower B*. 5uring the first -. hr postpartum, uterine contractions are strong and regular, and they continue for the next .1 days, although their fre%uency and intensity are reduced. ,actors intensifying afterpains include multiparity, uterine overdistension, "reastfeeding, and administration of ergot and oxytocin preparations. Relaxes muscles, and redirects attention away from painful sensations. *romotes comfort, and reduces unpleasant distractions, enhancing sense of well0"eing.

Reposition client, reduce noxious stimuli, and offer comfort measures, e.g., "ac+ ru"s. /ncourage use of "reathing and relaxation techni%ues and distraction (stimulation of cutaneous tissue) as learned in child"irth preparation classes. /ncourage presence and participation of partner as appropriate. &nitiate deep0"reathing exercises, incentive spirometry, and coughing using splinting procedures, as appropriate, 10 min after administration of analgesics.

5eep "reathing enhances respiratory effort. >plinting reduces strain and stretching of incisional area and lessens pain and discomfort associated with movement of a"dominal muscles. #oughing is indicated when secretions or rhonchi are auscultated. 5ecreases gas formation and promotes peristalsis to relieve discomfort of gas accumulation, which often pea+s on 1rd day after cesarean "irth.

/ncourage early am"ulation, use of roc+ing chair or left side0lying position, as appropriate. Recommend avoidance of gas0forming foods or fluids, e.g., "eans, ca""age, car"onated "everages, whole mil+, very hot or very cold "everages, or use of straws for drin+ing. (Refer to 95: #onstipation.) Recommend use of left lateral recum"ent position. &nspect perineum for hemorrhoids. >uggest application of ice for .0 min every 3 hr, use of witch ha2el compresses, and elevation of pelvis on pillow, as appropriate. *alpate "ladder, noting fullness. ,acilitate periodic voiding after removal of indwelling catheter. &nvestigate reports of headache, especially following su"arachnoid anesthesia. (void medicating client "efore nature and cause of headache are determined. 9ote character of headache (e.g., deep location "ehind the eyes, with pain radiating to "oth temples and occipital area' relieved in supine position "ut increased in sitting or standing position) to distinguish from headache associated with anxiety or *&6.

(llows gas to rise from descending to sigmoid colon, facilitating expulsion. (ids in regression of hemorrhoids and vulvar varicosities "y promoting venous return and locali2ed vasoconstriction, reducing associated edema, discomfort, and itching. Return of normal "ladder function may ta+e 3A days, and overdistension of "ladder may create feelings of urgency and discomfort. )ea+age of #>, through the dura mater into the extradural space reduces volume needed to support "rain tissue, causing the "rain stem to fall onto the "ase of the s+ull when client is in an upright position. *&6 may result in cere"ral edema, necessitating other interventions. (Refer to #*: 7he #lient at 3 6ours to . 5ays *ostpartum' 95: ,luid 8olume, ris+ for excess.)

/ncourage "edrest in flat0lying position, increase fluids, offer caffeinated "everage, assist as needed with client and infant care, and apply a"dominal "inder when client is upright, in presence of postspinal headache. 9otify physician or anesthesiologist, as indicated. &nspect "reast and nipple tissue' assess for presence of engorgement and$or crac+ed nipples.

Reduces severity of headache "y increasing fluid availa"le for production of #>, and limiting position shifts of the "rain. >evere headache may interfere with client<s a"ility to carry out self$infant care. ;ngoing headache may re%uire more aggressive therapy. (t .3 hr postpartum, "reasts should "e soft and nontender, with nipples free of crac+s or reddened areas. Breast engorgement, nipple tenderness, or presence of crac+s on nipple (if client is lactating) may occur .1 days postpartum and re%uire prompt intervention to facilitate continuation of "reastfeeding and prevent more serious complications. )ifts "reasts inward and upward, resulting in a more comforta"le position and decreasing muscle fatigue. 7hese measures can help the lactating client stimulate the flow of mil+ and relieve stasis and engorgement. =se of Bfoot"all holdC directs infant<s feet away from a"domen. *illow helps support infant and protects incision in sitting or side0lying position. &nitial suc+ling response is strong and may "e painful. >tarting feeding with unaffected "reast and then proceeding to involved "reast may "e less painful and enhance healing. =se of supportive "ra and ice suppresses lactation "y mechanical means and are the preferred method for cessation of lactation. 5iscomfort lasts approximately 3 A. hr "ut eases or ceases with avoidance of nipple stimulation.

/ncourage wearing of supportive "ra. *rovide information to the lactating client a"out increasing the fre%uency of feedings, applying heat to "reasts "efore feedings, proper positioning of the infant, and expressing mil+ manually. (Refer to #*: 7he #lient at 3 6ours to . 5ays *ostpartum' 95: Breastfeeding DspecifyE.) >uggest that client initiate feedings on nontender nipple for several feedings in succession if only one nipple is sore or crac+ed. (pply ice to axillary area of "reasts if the client is not planning to "reastfeed. Recommend use of well0fitting supportive "ra, and avoidance of excess exposure of "reasts to heat, or stimulation of "reasts "y infant, sexual partner, or client until suppression process is completed (approximately - w+).

C# !0#r!"i4&
(ssist with "olus dose of morphine sulfate (5uramorph) via epidural prior to removal of epidural catheter. (dminister analgesics every 13 hr, progressing from &8$&! (e.g., meperidine D5emerolE, "utorphanol D>tadolE, nal"uphine D9u"ainE) to oral route (e.g., oxycodone0acetaminophen D*ercocetE, oxycodone0aspirin D*ercodanE). !edicate lactating client 3460 min "efore "reastfeeding. Review$monitor use of patient0controlled analgesia (*#(s) as indicated. *rovides approximately .30hr period of pain control, at the end of which oral medications are usually appropriate. *romotes comfort, which improves psychological status and enhances mo"ility. =se of medication with limited a"ility to cross into mil+ allows lactating mother to en?oy feeding without adverse effects on infant.

*#( using meperidine or morphine may "e used to provide rapid pain relief without excessive side effects$oversedation. /nhances sense of control, general well0"eing, and independence. ;ccasionally necessary to relieve gas "uildup.

(dminister antiflatulent, e.g., !ylicon. *rovide rectal$nasogastric (9F) tu"e as indicated.

(ssist as needed with saline in?ection or administration of B"lood patchC over site of dural puncture. Ieep client in hori2ontal position following the procedure.

/ffective for relief of severe spinal headache. 7he "lood patch procedure, which has a G0H-00H success rate, creates a "lood clot, which produces pressure and seals the lea+.

NURSING DIAGNOSIS1 M!' B& R& !"&) T#1 P#++i0 ' E4i)&$c&) B'1

SELF ESTEEM/ +i"u!"i#$!

#8

*erceived failure at a life event, maturational transition, perceived loss of control in current situation 8er"ali2ation of negative feelings a"out self in situation (e.g., helplessness, shame$guilt), evaluates self as una"le to handle situation, difficulty ma+ing decisions 5iscuss concerns related to her$his role in and perception of the "irth experience. 8er"ali2e understanding of individual factors that precipitated current situation. /xpress positive self0appraisal.

DESIRED OUTCOMES*EVALUATION CRITERIA5CLIENT*COUPLE WILL1

ACTIONS*INTERVENTIONS I$)&-&$)&$"
5etermine client<s$couple<s emotional response to cesarean "irth.

RATIONALE

Both mem"ers of the couple may have a negative emotional reaction to the surgical intervention. (n unplanned cesarean "irth may have a negative effect on the client<s self0esteem, leaving her feeling that she is inade%uate and has failed as a woman. 7he father or partner, especially if he was una"le$unwilling to "e present at the cesarean delivery, may feel that he a"andoned his partner and did not fulfill his anticipated role as emotional supporter during the child"irth process. /ven though a healthy "a"y may "e the outcome, parents often grieve and feel a sense of loss at missing out on the anticipated vaginal "irth. #esarean "irth may "e viewed "y the client$ couple as a failure at a life event, and this may have a negative impact on the "onding$parenting process. 9ote: /mergency cesarean "irth may create pro"lems for care of si"lings "ecause of unexpected prolonged hospital stay. ,ather may encounter conflicts in spending time with client$infant and meeting needs of si"lings. Refocuses client<s$couple<s attention to help them view pregnancy in its totality and to see that their actions have contri"uted to an optimal outcome. !ay help to avoid guilt$placing of "lame. 9ote: Frief response may "e lessened if "oth mother and father were a"le to share in experience of delivery.

5etermine client<s level of anxiety and source of concern. /ncourage client$couple to ver"ali2e unmet needs and expectations. *rovide information regarding the normalcy of such feelings.

Review client<s$couple<s participation and role in "irth experience. &dentify positive "ehaviors during prenatal and antepartal process.

/ncourage presence$participation of partner in all that is going on. /mphasi2e similarities "etween vaginal and cesarean "irth. #onvey positive attitude, and manage postpartal care as close as possi"le to care provided to clients following vaginal "irth.

*rovides emotional support' may encourage ver"ali2ation of concerns. #lient may alter her perception of cesarean "irth experience as well as her perception of her own wellness or illness "ased on the professional<s attitudes. >imilar care conveys the message that cesarean "irth is a necessary alternative to vaginal delivery, focusing on the optimal outcome rather than on the "irth process. 6elps facilitate positive adaptation to new role' reduces feelings of inade%uacy.

(ssist client$couple in identifying usual coping mechanisms and developing new coping strategies if needed. (Refer to #*: 7he #lient at 3 6ours to . 5ays *ostpartum' 95: #oping, &ndividual, ris+ for ineffective.) *rovide accurate information a"out client$ infant status.

,antasies caused "y lac+ of information or misunderstanding may increase sense of helplessness$loss of control.

#olla"orative
Refer client$couple for professional counseling if reactions are maladaptive. #lient who is una"le to resolve grief or negative feelings may need further professional help.

NURSING DIAGNOSIS1 Ri+: F!c"#r+ M!' I$c u)&1

IN9URY/ ri+: ,#r Biochemical or regulatory functions (e.g., orthostatic hypotension, development of *&6 or eclampsia), effects of anesthesia, throm"oem"olism, a"normal "lood profile (anemia$excessive "lood loss, ru"ella sensitivity, Rh incompati"ility), tissue trauma D9ot applica"le' presence of signs$symptoms esta"lishes an actual diagnosisE 5emonstrate "ehaviors to reduce ris+ factors and$or protect self. Be free of avoida"le complications.

P#++i0 ' E4i)&$c&) B'1 DESIRED OUTCOMES*EVALUATION CRITERIA5CLIENT WILL1

ACTIONS*INTERVENTIONS I$)&-&$)&$"
Review prenatal and intrapartal record for factors that predispose client to complications. 9ote 6" level and operative "lood loss.

RATIONALE

*resence of ris+ factors, such as myometrial fatigue, uterine overdistension, prolonged oxytocin stimulation, general anesthesia, anemia$excessive "lood loss, or prenatal throm"ophle"itis renders the client more suscepti"le to postoperative complications.

!onitor B*, pulse, and temperature. 9ote cool, clammy s+in' wea+, thready pulse' "ehavior changes' delayed capillary refill' or cyanosis. (Refer to #*: *ostpartal 6emorrhage.) /ncourage early am"ulation and exercise, except in client who received su"arachnoid anesthesia who may remain flat for 6 hr without use of pillow or raising head, as indicated "y protocol and return of sensation$muscle control. (Refer to 95: *ain DacuteE$D5iscomfortE.) (ssist client with initial am"ulation. *rovide ade%uate supervision in shower or sit2 "ath. )eave call "ell within client<s reach. 6ave client sit on floor or chair with head "etween legs, or have her lie down in a flat position, if she feels faint. =se ammonia capsule (Bsmelling saltsC). (ssess for hyperreflexia, R=J$epigastric pain, headache, or visual distur"ances. !aintain sei2ure precautions, and provide %uiet environment as indicated. (Refer to #*: 7he #lient at 3 6ours to . 5ays *ostpartum' 95: ,luid 8olume, ris+ for excess' #*: *regnancy0&nduced 6ypertension' 95: &n?ury, ris+ for.) 9ote effects of !g>;3, if administered. (ssess patellar response and monitor respiratory rate. &nspect incision regularly' note signs of delayed or altered healing (e.g., lac+ of approximation). &nspect lower extremities for signs of throm"ophle"itis (e.g., redness, warmth, pain$ tenderness). 9ote presence or a"sence of 6omans< sign. (Refer to #*: *ostpartal 7hrom"ophle"itis.)

/levated B* may indicate developing or continuing hypertension, necessitating !g>;3 or other antihypertensive treatment. 6ypotension and tachycardia may reflect dehydration and hypovolemia. *yrexia may indicate infection. /nhances circulation and venous return of lower extremities, reducing ris+ of throm"us formation, which is associated with stasis. (lthough recum"ent position after su"arachnoid anesthesia is de"ata"le (no research to date supports effectiveness), it may aid in prevention of #>, lea+age and resultant headache. ;rthostatic hypotension may occur when changing from supine to upright position on initial am"ulation, or it may result from vasodilation caused "y the heat of the shower or sit2 "ath. 6elps maintain or enhance circulation and delivery of oxygen to "rain. 5anger of eclampsia due to *&6 exists for up to A. hr postpartum, although literature suggests the convulsive state has occurred as late as the 4th day postpartum.

("sence of patellar reflex and respiratory rate "elow -.$min indicates toxicity and a need to reduce or discontinue drug therapy. /xcessive strain on the incision or delayed healing may render client prone to tissue separation and possi"le hemorrhage. /levated fi"rin split products (possi"ly released from placental site), reduced mo"ility, trauma, sepsis, and extensive activation of "lood clotting following delivery predispose the client to the development of throm"oem"olism. 6omans< sign may "e present with deep venous throm"us, "ut may "e a"sent with superficial phle"itis. &n addition, plasma losses, elevated platelet counts, and relaxation of "lood vessels from anesthesia increase ris+ for throm"ophle"itis. *romotes venous return' prevents stasis$pooling in lower extremities, reducing ris+ of phle"itis. 8accination helps prevent teratogenic effects in su"se%uent pregnancies. (dministration of vaccine in the immediate postpartal period may cause side effects of transient arthralgia, rash, and cold symptoms during incu"ation period of -3.days. (llergic anaphylactic or hypersensitivity response may occur, necessitating administration of epinephrine.

/ncourage leg$an+le exercises and early am"ulation. /valuate client<s ru"ella status on prenatal chart (K-:-0 titer indicates suscepti"ility). (ssess client for allergies to eggs or feathers' if present, vaccine is contraindicated. *rovide written and oral information, and o"tain informed consent for vaccination after reviewing side effects, ris+s, and the necessity to prevent conception for .1 mo following the vaccination.

C# !0#r!"i4&
(dminister !g>;3 "y infusion pump, as indicated. 6elps reduce cere"ral irrita"ility in presence of *&6 or eclampsia. (Refer to #*: 7he #lient at 3 6ours to . 5ays *ostpartum' 95: ,luid 8olume, ris+ for excess.) Reduces venous stasis, enhancing venous return and reducing ris+ of throm"us formation. (lthough usually not re%uired, may help prevent further development of throm"us. 5ose of 100 mg is usually sufficient to promote lysis of fetal Rh0positive RB#s that may have entered maternal circulation during delivery and that may potentially cause sensiti2ation and pro"lems of Rh incompati"ility in su"se%uent pregnancies. *resence of .0 ml or more of Rh0 positive fetal "lood in maternal circulation necessitates higher dose of Rh&gF. 9ote: &f drug is not administered within A. hr of delivery, a window of opportunity exists for up to . w+, although the degree of effectiveness may "e reduced.

(pply support hose or elastic wrap to legs when ris+ or symptoms of phle"itis are present. (dminister anticoagulant' evaluate coagulation factors, and note signs of failure to clot. (Refer to #*: *ostpartal 7hrom"ophle"itis.) (dminister Rh&gF &! within A. hr postpartum, as indicated for Rh0negative mother who has not "een previously sensiti2ed and who delivers an Rh0positive infant with negative result on direct #oom"s< test on cord "lood. ;"tain Bet+e0 Ileihauer smear if significant fetal0maternal transfusion is suspected at delivery.

NURSING DIAGNOSIS1 Ri+: F!c"#r+ M!' I$c u)&1

INFECTION/ ri+: ,#r 7issue trauma$"ro+en s+in, decreased 6", invasive procedures and$or increased environmental exposure, prolonged rupture of amniotic mem"ranes, malnutrition D9ot applica"le' presence of signs$symptoms esta"lishes an actual diagnosisE 5emonstrate techni%ues to reduce ris+s and$or promote healing. 5isplay wound free of purulent drainage with initial signs of healing (i.e., approximation of wound edges), uterus soft$nontender, with normal lochial flow and character. Be free of infection, "e afe"rile, have no adven0titious "reath sounds, and void clear am"er urine.

P#++i0 ' E4i)&$c&) B'1 DESIRED OUTCOMES*EVALUATION CRITERIA5CLIENT WILL1

ACTIONS*INTERVENTIONS I$)&-&$)&$"
/ncourage and use careful hand washing techni%ue and appropriate disposal of soiled underpads, perineal pads, and contaminated linen. 5iscuss with client the importance of continuing these measures after discharge.

RATIONALE

6elps prevent or retard spread of infection.

Review prenatal 6"$6ct' note presence of conditions$ris+ factors that predispose client to postoperative infection.

(nemia, o"esity, dia"etes, prolonged la"or (especially with mem"ranes ruptured) prior to cesarean delivery, corticosteroid therapy, malnutrition, smo+ing, and chronic lung disease increase the ris+ of infection and delayed healing. #lient who is .0H "elow normal weight, or who is anemic or malnourished, is more suscepti"le to postpartal infection and may have special dietary needs. *revents dehydration' maximi2es circulation and urine flow. *rotein and vitamin # are needed for collagen formation' iron is needed for 6" synthesis. ( sterile dressing covering the wound in the first .3 hr following cesarean "irth helps protect it from in?ury or contamination. ;o2ing may indicate hematoma, loss of suture approximation, or wound dehiscence, re%uiring further intervention. Removing the dressing allows incision to dry and promotes healing. !oist environment is an excellent medium for "acterial growth' "acteria can travel "y capillary action through the wet dressing to the wound. 9ote: &ncision into the lower uterine segment heals more rapidly than classic incision and is less li+ely to rupture in su"se%uent pregnancies. 7hese signs indicate wound infection, usually caused "y streptococci, staphylococci, or Pseudomonas species. 9ote: @ound infections are usually clinically apparent 1 days after the procedure.

(ssess client<s nutritional status. 9ote appearance of hair, fingernails, s+in, and so forth. 5etermine prepregnancy weight and prenatal weight gain. /ncourage oral fluids and diet high in protein, vitamin #, and iron. &nspect a"dominal dressing for exudate or oo2ing. Remove dressing, as indicated.

9ote operative record for use of drain and nature of incision. #lean wound and change dressing when wet.

&nspect incision, evaluate healing process, noting locali2ed redness, edema, pain, exudate, or loss of approximation of wound edges.

(ssist as needed with removal of s+in sutures or clips. &ncision is usually sufficiently healed to remove sutures on the 3th or 4th day following surgical procedure. /ncourage client to ta+e warm showers daily. >howers, usually allowed after the .nd postoperative day, promote hygiene and may stimulate circulation and healing of wound. 9ote: &n some cultures, showers$tu" "aths are avoided until lochial flow ceases or longer, as dictated. ,ever after the 1rd postoperative day, leu+ocytosis, and tachycardia suggest infection. /levation of temperature to -0-L, (1 .1L#) within the first .3 hr is highly indicative of infection' an elevation to -00.3L, (1 .0L#) on any . of the -st -0 days postpartum is significant. ,ollowing cesarean "irth, the fundus remains at the level of the um"ilicus for up to 4 days, when involution "egins, accompanied "y an increase in lochial flow. 5elayed involution increases the ris+ of endometritis. 5evelopment of extreme tenderness signals possi"le retained placental tissue or infection.

(ssess temperature, pulse, and @B# count.

(ssess location and contractility of uterus' note involutional changes or presence of extreme uterine tenderness.

9ote amount and odor of lochial discharge or change in normal progression from ru"ra to serosa.

)ochia normally has a fleshy odor' however, in endometritis, the discharge may "e purulent and foul0smelling, and may fail to demonstrate normal progression from ru"ra to serosa to al"a. *revents introduction of "acteria when indwelling catheter is used and avoids urinary reflux, reducing ris+ of infection. 6elps eliminate medium of "acterial growth' promotes hygiene. =rinary stasis increases the ris+ of infection. #loudy or malodorus urine indicates presence of "acteria. Rest reduces meta"olic process, allowing oxygen and nutrients to "e used for healing. >emi0,owler<s position promotes flow of lochia and reduces pooling in uterus, and maximi2es respiratory function. &ndicates local infection, re%uiring removal of catheter and possi"ly restarting the &8 line in another site. 7he development of nipple fissures$crac+s potentiates ris+ of mastitis.

!aintain sterile, closed in?ury drainage system with drainage "ag in dependent position. *rovide perineal and catheter care, per protocol. 9ote fre%uency$amount and characteristics of urine. *romote rest and encourage use of semi0,owler<s position once anesthesia precautions are completed.

&nspect &8 site for signs of erythema or tenderness. /valuate condition of nipples, noting presence of crac+s, redness, or tenderness. Recommend routine examination of "reasts. Review proper care and infant feeding techni%ues. (Refer to 95: *ain DacuteE$D5iscomfortE.) (ssess lung sounds and respiratory ease or effort. 9ote crac+les$rhonchi, dyspnea, chest pain, fever, or mucopurulent sputum.

Rhonchi indicative of retained secretions should not "e present, yet "reath sounds may "e diminished for the first .3 hr after surgery. ("sence of lung sounds indicates consolidation or lac+ of air exchange, suggesting atelectasis or possi"ly pneumonia. 9ote: (telectasis usually occurs in the first A. hr after the procedure, whereas pneumonia typically develops after A. hr. &mproves depth of respirations and alveolar expansion' clears secretions that could "loc+ "ronchioles. *roductive cough indicates client is clearing "ronchial secretions effectively. >plinting prevents excessive strain on incision, reducing discomfort and enhancing client<s participation in activity.

&nstitute turning, coughing, and deep0"reathing routines with splinting of incision every .3 hr while awa+e. 9ote productive cough.

C# !0#r!"i4&
(dminister oxytocin or ergot preparation. (9ote: ;xytocin infusion is often ordered routinely for 3 hr following surgery.) !onitor la"oratory test results, such as B=9 and .30hr urine, for total protein, creatinine clearance, and uric acid, as indicated. !aintains myometrial contractility, there"y retarding "acterial spread through walls of uterus' aids in expulsion of clots$mem"ranes. &n the client who has had *&6, +idney or vascular involvement may persist, or it may appear for the first time during the postpartal period. (s steroid levels decrease following delivery, renal function, evidenced "y B=9 and creatinine clearance, "egins to return to normal within - w+' anatomic changes (e.g., dilation of ureters and renal pelvis) may ta+e up to - mo to return to normal.

(dminister prophylactic anti"iotic infusion, with first dose usually administered immediately after cord clamping and two more doses 6 hr apart. 5emonstrate$encourage use of incentive spirometer. ;"tain sputum specimen as indicated "y changes in color or odor of sputum, presence of congestion, and temperature elevation. Review chest x0rays, as indicated. ;"tain "lood, vaginal, and urine cultures, if infection is suspected.

5ecreases li+elihood of postpartal endometritis as well as complications such as incisional a"scesses or pelvic throm"ophle"itis. *romotes sustained maximal respiration, inflates alveoli, and prevents atelectasis. &dentifies specific pathogens and appropriate therapy. #onfirms presence of infiltrate(s) or atelectasis. Bacteremia is more fre%uent in client whose mem"ranes were ruptured for 6 hr or longer than in client whose mem"ranes remained intact prior to cesarean "irth. 9ecessary to effectively eradicate organism.

(dminister specific anti"iotic for identified infectious process.

NURSING DIAGNOSIS1 Ri+: F!c"#r+ M!' I$c u)&1 P#++i0 ' E4i)&$c&) B'1 DESIRED OUTCOMES*EVALUATION CRITERIA5CLIENT WILL1

FLUID VOLUME/ ri+: ,#r )&,ici" *eriod of restricted oral inta+e, presence of nausea$vomiting, excessive "lood loss during surgery D9ot applica"le' presence of signs$symptoms esta"lishes an actual diagnosisE !aintain fluid volume at a functional level as evidenced "y individually ade%uate urinary output, sta"le vital signs, moist mucous mem"ranes, and 6"$6ct within normal limits.

ACTIONS*INTERVENTIONS I$)&-&$)&$"
Review prenatal and intrapartal$surgical records for 6" level, operative "lood loss, fluid replacement, presence of edema. !onitor B*, pulse, status of mucous mem"ranes, capillary refill' note presence of cyanosis.

RATIONALE

5ata helpful in evaluating current fluid status and potential for diuresis. 6ypotension, tachycardia, and dry mouth may reflect dehydration and hypovolemia "ut may not occur until circulating "lood volume has decreased "y 10H40H, at which time signs of peripheral vasoconstriction may "e noted. >urgical wounds with a drain may saturate a dressing' however, oo2ing is usually not expected and may suggest developing complications.

&nspect dressing for excessive "leeding. ;utline, date drainage on dressings (if not changed). 9otify physician of continued oo2ing.

9ote character and amount of lochial flow and consistency of fundus. Fently massage fundus as indicated.

)ochial flow should not "e heavy or contain clots' fundus should remain firmly contracted at the um"ilicus. ( "oggy uterus results in increased flow and "lood loss. 9ote: (s a rule, lochial flow is usually decreased "y second postoperative day, thus BnormalC amount of flow expected after vaginal delivery would "e suspect for this client. Iidney function is a +ey index to circulating "lood volume. (s output decreases, specific gravity increases, and vice versa. Bloody urine or urine containing clots signifies possi"le "ladder trauma associated with surgical intervention.

!onitor fluid inta+e and urine output. 9ote appearance, color, concentration, and specific gravity of urine.

/ncourage ade%uate oral fluids (e.g., 6 glasses$day). *referred route for replacement once nausea is resolved$peristalsis returns. (de%uate inta+e allows for timely removal of &8.

C# !0#r!"i4&
Replace fluid losses intravenously, as indicated. (verage "lood loss is usually 600 00 ml, "ut prenatal physiological edema, which mo"ili2es postpartum, alleviates need for large fluid volume replacement. ( total of 1 ) of fluid infused intravenously in the intraoperative and early postoperative (.30hr) period is recommended. 9ote: &f epidural anesthesia is used, more fluids are usually re%uired. #lient with 6ct of 11H or greater and increased plasma associated with pregnancy can usually tolerate actual "lood loss of up to -400 ml without difficulty. ( significant change in volume may necessitate replacement with "lood products, although iron replacement may "e preferred. >timulates myometrial contractility and reduces "lood loss. ;xytocin is usually added to infusion intraoperatively after delivery of the infant<s shoulders and is maintained into the early postoperative period.

!onitor postoperative 6"$6ct' compare with preoperative levels.

&ncrease oxytocin infusion if uterus is relaxed and$ or lochia is heavy.

NURSING DIAGNOSIS1 M!' B& R& !"&) T#1

CONSTIPATION 5ecreased muscle tone (diastasis recti, excess analgesia or anesthesia), effects of progesterone, dehydration, prela"or diarrhea, lac+ of inta+e, perineal$rectal pain Reported a"dominal$rectal fullness or pressure, nausea, less than usual amount of stool, straining at stool, decreased "owel sounds 5emonstrate return of intestinal motility, as evidenced "y active "owel sounds and the passing of flatus.

P#++i0 ' E4i)&$c&) B'1

DESIRED OUTCOMES*EVALUATION CRITERIA5CLIENT WILL1

Resume usual$optimal elimination pattern within 3 days postpartum.

ACTIONS*INTERVENTIONS I$)&-&$)&$"
(uscultate for presence of "owel sounds in all four %uadrants every 3 hr following cesarean "irth.

RATIONALE

5etermines readiness for oral feedings, and possi"le developing complication, e.g., ileus. =sually, "owel sounds are not heard on the -st day after surgical procedure, are faint on the .nd day, and are active "y the 1rd day. &ndicates gas formation and accumulation or possi"le paralytic ileus. &ndicates return of motility. Roughage (e.g., fruits and vegeta"les, especially with seeds and s+ins) and increased fluids provide "ul+, stimulate elimination, and prevent constipated stool. 9ote: ,ood or fluid offered "efore return of peristalsis may contri"ute to paralytic ileus. )eg exercises tighten a"dominal muscles and improve a"dominal motility. *rogressive am"ulation after .3 hr promotes peristalsis and gas expulsion, and alleviates or prevents gas pains. 6elps in re0esta"lishing normal evacuation pattern and promotes independence.

*alpate a"domen, noting distension or discomfort. 9ote passing of flatus or "elching. /ncourage ade%uate oral fluids (e.g., 6 glasses$ day) once oral inta+e resumes. Recommend increased dietary roughage and fruits and vegeta"les. /ncourage leg exercises and a"dominal tightening' promote early am"ulation.

&dentify those activities that client can use at home to stimulate "owel action.

C# !0#r!"i4&
(dminister analgesics 10 min "efore am"ulation. *rovide stool softener or mild cathartic. (dminister hypertonic or small soap suds enema. &nsert or maintain 9F tu"e as indicated. ,acilitates a"ility to am"ulate' however, narcotics, if used, may reduce "owel activity. >oftens stool, stimulates peristalsis, and helps re0 esta"lish "owel function. *romotes "owel evacuation and relieves gaseous distension. !ay "e necessary to decompress the stomach and relieve distension associated with paralytic ileus.

NURSING DIAGNOSIS1

;NOWLEDGE )&,ici" 6LEARNING NEED7/ r&%!r)i$% -3'+i# #%ic! c3!$%&+/ r&c#4&r' -&ri#)/ +& , c!r&/ !$) i$,!$" c!r& $&&)+ )ac+ of exposure$recall, misinterpretation, unfamiliarity with resources 8er"ali2ed concerns$misconceptions, hesitancy in or inade%uate performance of activities, inappropriate

M!' B& R& !"&) T#1 P#++i0 ' E4i)&$c&) B'1

"ehaviors (e.g., apathy) DESIRED OUTCOMES*EVALUATION CRITERIA5CLIENT WILL1 8er"ali2e understanding of physiological changes, individual needs, expected outcomes. *erform necessary activities$procedures correctly and explain reasons for the actions.

ACTIONS*INTERVENTIONS I$)&-&$)&$"
(ssess client<s readiness and motivation for learning. (ssist client$couple in identifying needs.

RATIONALE

7he postpartal period can "e a positive experience if opportune teaching is provided to foster maternal growth, maturation, and competence. 6owever, the client needs time to move from a Bta+ing inC to a Bta+ing holdC phase, in which her receptiveness and readiness is heightened and she is emotionally and physically ready for learning new information to facilitate mastery of her new role. (lthough "asic information may "e provided$reviewed the -st day, the client is usually receptive to learning more in0 depth material "y the .nd or 1rd day postpartum. 6elps assure completeness of information parents receive from staff mem"ers and reduces client confusion caused "y dissemination of conflicting advice or information. 5iscomfort associated with incision or afterpains, or "owel$"ladder discomfort, is usually less severe "y the .nd or 1rd postoperative day, allowing the client to concentrate more fully and "e more receptive to learning. (nxiety related to a"ility to care for herself and her child, possi"le disappointment over the "irth experience, or concerns regarding her separation from the infant may have a negative impact on client<s learning a"ilities and readiness.

&nitiate written teaching plan using standardi2ed format, chec+list, or clinical pathway. 5ocument information given and client<s response. (ssess client<s physical status. *lan group or individual sessions following administration of medication or when client is comforta"le and rested.

9ote psychological state and response to cesarean "irth and mothering role. (Refer to 95: >elf /steem, situational low.)

*rovide information related to normal physiological 6elps client to recogni2e normal changes from and psychological changes associated with cesarean a"normal responses that may re%uire treatment. "irth and needs associated with the postpartal period. #lient<s emotional state may "e somewhat la"ile at this time and often is influenced "y physical well0 "eing. (nticipating such changes may reduce the stress associated with this transition period that necessitates learning new roles and ta+ing on new responsi"ilities. 9ote: #lient has had a ma?or a"dominal surgical procedure re%uiring at least 6 w+ for physiological recovery, "ut client may not feel fully recovered for up to 6 mo. >tress importance of ade%uate rest, fluid$dietary inta+e, and necessity for specific activity limitations (e.g., avoidance of lifting and driving). *romotes healing, facilitates recovery, protects incisionMreducing ris+ of dehiscence.

Review self0care needs (e.g., perineal care, incisional care, hygiene, voiding). /ncourage participation in self0care, as client is a"le. 5emonstrate method of getting out of a flat "ed without the use of siderails.

,acilitates autonomy, helps prevent infection, and promotes healing. By turning on her side, using her arms to lift herself to a sitting position, and pushing with her hands to lift "uttoc+s off the "ed to a standing position, client can continue to ease stress on incision after discharge. ( progressive exercise program can usually "e started once a"dominal discomfort has eased ("y approximately 13 w+ postpartum). 6elps tone musculature, increases circulation, produces a trimmer figure, and enhances feelings of general well0"eing. #lient should "e advised not to lift o"?ects heavier than the infant for approximately . w+, and to "end at +nees when lifting "a"y. *rompt evaluation and intervention may prevent$limit development of complications (e.g., hemorrhage, infection, delayed healing).

5iscuss prescri"ed exercise program.

&dentify signs$symptoms re%uiring notification of healthcare provider (e.g., fever, dysuria, increase in amount of lochial flow or return to "right red lochial exudate, or separation of suture line). 5emonstrate techni%ues of infant care. ;"serve return demonstration "y client$couple. (Refer to #*: 7he 9eonate at . 6ours to . 5ays of (ge' 95: Inowledge deficit D)earning 9eedE.) Review information regarding appropriate choice for infant feeding (e.g., physiology of "reastfeeding, diet, positioning, "reast and nipple care, and removal of infant from "reast' formula types$ preparation, infant position during "ottle feeding, "urping techni%ues). 5iscuss plans for home management: assistance with housewor+, physical layout of house, infant sleeping arrangements.

(ssists parents in mastery of new tas+s.

*romotes independence and optimal feeding experience. @hen "ottle feeding, it is important to feed the infant alternately on the right and left side to promote eye development. >light dehydration or physical or emotional trauma may delay onset of lactation for the client who has undergone a cesarean "irth. #lient who has undergone cesarean "irth may need more assistance when first home than the client who has given "irth vaginally. >tairs and the use of low cradles or "assinets may cause difficulties for the postoperative client. 6elps to identify individual needs, necessity of home visitation, and provides opportunity to correct misconceptions$unrealistic expectations. *romotes pro"lem solving. *rovides ready resources to answer %uestions. *romotes independence and provides support for adaptation to multiple changes. &ntercourse may "e resumed as soon as it is comforta"le for the client and healing has progressed, generally 36 w+ postpartum. #ouple may need clarification regarding availa"le contraceptive methods and the fact that pregnancy could occur even prior to the 360w+ visit. *ostpartum evaluations for the client who has undergone cesarean delivery may "e scheduled at 1 w+ rather than 6 w+ "ecause of increased ris+ of infection and delayed healing.

5etermine availa"ility of support system(s), plans after discharge.

*rovide num"ers for appropriate telephone contacts. &dentify availa"le community resources' e.g., visiting nurse$home care services, *u"lic 6ealth >ervice, @&# program, )a )eche )eague, !others of 7wins. 5iscuss resumption of sexual intercourse and plans for contraception. *rovide information a"out availa"le methods, including advantages and disadvantages. (Refer to #*: - @ee+ ,ollowing 5ischarge' 95: Inowledge deficit D)earning 9eedE.) *rovide or reinforce information related to follow0 up postpartal examination.

NURSING DIAGNOSIS1 M!' B& R& !"&) T#1

URINARY ELIMINATION/ ! "&r&) !echanical trauma$diversion, hormonal effects (fluid shifts and$or increased renal plasma flow), effects of anesthesia &ncreased "ladder filling$distension, changes in amount$fre%uency of voiding Resume usual$optimal voiding patterns following catheter removal. /mpty "ladder with each void.

P#++i0 ' E4i)&$c&) B'1 DESIRED OUTCOMES*EVALUATION CRITERIA5CLIENT WILL1

ACTIONS*INTERVENTIONS I$)&-&$)&$"
9ote and record amount, color, and concentration of urinary drainage.

RATIONALE

;liguria (output less than 10 ml$hr) may "e caused "y excess fluid loss, inade%uate fluid replacement, or antidiuretic effects of infused oxytocin. #atalytic process associated with uterine involution may result in normal proteinuria (-N) for the first . days postpartum. (cetone may indicate dehydration associated with prolonged la"or and$or delivery. ,luids promote hydration and renal function, and help prevent "ladder stasis. Renal plasma flow, which increases "y .4H40H during the prenatal period, remains elevated in the -st w+ postpartum, resulting in increased "ladder filling. Bladder distension can "e assessed "y degree of uterine displacement' causes increased uterine relaxation and lochial flow. *resence of indwelling catheter predisposes client to introduction of "acteria and =7&. (Refer to 95: &nfection, ris+ for.) #lient should void within 6 hr following catheter removal, yet may have difficulty emptying "ladder completely. *erforming Iegel exercise -00 times$day increases circulation to perineum, aids in healing and recovery of tone of pu"ococcygeal muscle, and prevents or reduces stress incontinence.

7est urine for al"umin and acetone. 5istinguish "etween proteinuria associated with *&6 and that associated with normal processes (Refer to #*: 7he #lient at 3 6ours to . 5ays *ostpartum' 95: ,luid 8olume, ris+ for excess.) *rovide oral fluid, e.g., 6 glasses per day, as appropriate. *alpate "ladder. !onitor fundal height and location and amount of lochial flow.

9ote signs and symptoms of =7& (e.g., cloudy color, foul odor, "urning sensation, or fre%uency) following catheter removal. =se methods to facilitate voiding after catheter removal (e.g., run water in sin+, pour warm water over perineum). &nstruct client to perform Iegel exercise daily after effects of anesthesia have su"sided.

C# !0#r!"i4&
!aintain &8 infusion for .3 hr following surgery, as indicated. &ncrease infusion rate if output is 10 ml$hr or less. =sually, 1 ) of fluid, including lactated Ringer<s solution, is ade%uate to replace losses and maintain renal flow$urine output.

Remove catheter per protocol$as indicated.

Fenerally, catheter may "e safely removed "etween 6-. hr postpartum' "ut for convenience it may remain in client until the morning after surgery. &n the client who has had *&6, +idney or vascular involvement may persist, or it may appear for the first time during the postpartal period. (s steroid levels decrease following delivery, renal function, evidenced "y B=9 and creatinine clearance, "egins to return to normal within - w+' anatomic changes (e.g., dilation of ureters and renal pelvis) may ta+e up to - mo to return to normal.

!onitor la"oratory test results, such as B=9 and .30hr urine for total protein, creatinine clearance, and uric acid, as indicated.

NURSING DIAGNOSIS1 M!' B& R& !"&) T#1 P#++i0 ' E4i)&$c&) B'1 DESIRED OUTCOMES*EVALUATION CRITERIA5CLIENT WILL1

SELF CARE )&,ici" 6+-&ci,' "'-&* &4& 7 /ffects of anesthesia, decreased strength and endurance, physical discomfort 8er"ali2ation of ina"ility to participate at level desired 5emonstrate techni%ues to meet self0care needs. &dentify$use availa"le resources.

ACTIONS*INTERVENTIONS I$)&-&$)&$"
(scertain severity$duration of discomfort. 9ote presence of postspinal headache.

RATIONALE

&ntense pain affects emotional and "ehavioral responses, so that the client may "e una"le to focus on self0care activities until her physical needs for comfort are met. &ntense headache associated with upright position re%uires modification of activities and additional assistance to meet individual needs. *hysical pain experience may "e compounded "y mental pain that interferes with client<s desire and motivation to assume autonomy. >ome cultures, (e.g., !exican$(ra"0(merican, 6aitian, Russian) re%uire the new mother to o"serve a specified period of "ed rest$activity restrictions during which other female mem"ers of her family may provide care. /pidural anesthesia (especially following "olus dose of duramorph) may cause generali2ed wea+ness, creating safety concerns, and re%uires careful assessment "efore sitting upright$getting out of "ed. #lients who have undergone spinal anesthesia may "e directed to lie flat and without pillow for several hours following administration of anesthesia.

(ssess client<s psychological status.

9ote cultural expectations$practices.

5etermine type of anesthesia, and associated orders or protocol regarding positioning$ am"ulation.

Reposition client every -. hr' assist with pulmonary exercises, am"ulation, and leg exercises.

6elps prevent surgical complications such as phle"itis or pneumonia, which may occur when discomfort levels interfere with client<s normal repositioning$activity. &mproves self0esteem' increases feelings of well0 "eing. (llows some autonomy, even though client depends on professional assistance. 9ote: >ome cultures restrict "athing$showers for a predetermined length of time after delivery or until cessation of lochial flow.

;ffer assistance as needed with hygiene (e.g., mouth care, "athing, "ac+ ru"s, and perineal care). ;ffer choices when possi"le (e.g., selection of ?uices, scheduling of "ath, destination during am"ulation).

C# !0#r!"i4&
(dminister analgesic agent every 13 hr, as needed. #onvert &8 line to saline loc+, as appropriate. Reduces discomfort, which could interfere with a"ility to engage in self0care. *ermits unrestricted movement of extremities, there"y allowing client to function more independently, regardless of ongoing intermittent &8 therapy (e.g., anti"iotics).