JG COLLEGE OF NURSING

AHMEDABAD

Subject : Obstetrics & Gynecological Nursing

Nursing Process Of LSCS

SUBMITTED TO: SUBMITTED BY:

MS. MURIAL CHRISTIE MS. JUHI LABANA
ASSOCIATE PROFESSOR S.Y. M.Sc. (N)
JGCON, AHMEDABAD JGCON, AHMEDABAD
Nursing Process on Lower Segment Cesarean Section

Nursing diagnosis:

1. Ineffective individual coping related to surgical intervention.

2. Pain related to surgical incision.

3. Risk for fluid volume deficit related to blood loss associated with surgery, underlying
conditioned that necessitate surgery and uterine hypo- tonicity.

4. Risk for maternal infection related to delivery and secondary to surgical incision.

5. The patient will develop minimal squeal from inactivity and will progressively
increase.
 Theory Assessment Nursing Objective Planning Rationale Implementation Evaluation
diagnosis
Adaptation Subjective data Ineffective The patient Accept the An inability to The patient The patient
theory by sister Mrs. Hetal I individual will exhibit patient reaction to cope may take reaction have exhibit
callista Roy am scare of coping positive cesarean section birth. various form; subtle been noted. positive
focus on the operation related to coping . outcome as
Note the isolation, lack manifestation may
collecting data and about my surgical of concentration, silence signal an inability to evidence by
related to baby intervention. or repeatedly asking cope. verbalization
adaptation
condition questions. of feelings and
mode i.e.,
physiological no signs of
Objective data Allow the This will help in Listens to inconsolable
mode
In this mrs.
she is crying, patient to express her reducing anxiety. the patient . crying
Sashikala s anxious and feelings.
behavior expressing her
response to feelings.
Reinforce the Focusing on birth Explained
surgical
preparatory teaching is a positive activity about the
intervention.
.focus on the birth and may lessen birthing process.
experience and the disappointment and
commonalities between guilt.
vaginal and cesarean
birth.

Reassure the The patient may Reassured

patient that she may think that future the patient.
deliver vaginally in the deliveries must be by
future. cesarean, and feel
anxious.
 Theory Assessment Nursing Objective Planning Rationale Implementation Evaluation
diagnosis
Adaptation Subjective data Pain related The patient Assess the patients Assessment Assess location, The patient
theory by I am having to surgical will pain including location, helps to direct severity and feel less
sister callista pain in stitching incision. experience severity, duration. intervention. aggravating factors experienced of
Roy focus area. less pain. of pain, ask client the pain as
on collecting Perform comfort These techniques rate on 0-10 evidence by
data related to measures and relaxation enhance
verbalization
adaptation Objective data: techniques. pharmacologic
of feelings.
mode i.e., There is edema analgesia and give Comfort
physiological and redness in the patient a sense of measures have been
mode the stitching control. provided.
In this Mrs. area.
Hetal's Administer Pharmacologic Administer
behavior analgesics analgesia is meperidine
response to as per doctors order. necessary for 48 intravenous.
surgical hours or more
intervention. because of surgical
manipulation.

Assess the patients To assess the The patient

response to effectiveness of the condition is assessed.
pharmacologic pain given medicine
management.
 Theory Assessment Nursing Objective Planning Rationale Implementation Evaluation
diagnosis
Adaptation Subjective Risk for Establishmen Assess the patients Change in vital Vital sign is Fluid volume is
theory by sister data fluid volume t of the vital sign every 15 min. sign indicates assessed every 15 maintained
callista Roy I am having deficit patient fluid complications. min.
focus on weakness and related to level
collecting data having vertigo. blood loss Assess the number of Significant fluid Number of
related to associated perineal pads used. loss can be dictated.perineal pads used is
adaptation with surgery, assessed.
mode i.e., Objective underlying Assess the lochia for Caesarean results Monitor lochia
physiological data: conditioned colour, amount and in less lochia for foul smell, and
mode There is dry that odour. postpartum, if more colour.
In this Mrs. mouth and necessitate indicate infection.
Hetal's hypotension of surgery and
behavior the patient. uterine Use strict aseptic Reduce the risk Use strict aseptic
response to hypo- technique when of nosocomial technique.
fluid loss. tonicity. performing dressings. infection.

Assess incision for Helps to detect Incision site is

active bleeding, seepage, signs of infection. checked for any sign
approximation of edges, of infection.
and hematoma formation.

Administer I.V. fluid Administer

intravenous fluid. enhances circulating ringer lactate
blood volume and solution .
minimizes sequelae
of loss.
 Theory Assessment Nursing Objective Planning Rationale Implementation Evaluation
diagnosis
Betty Subjective Risk for The patient Monitor the Pyrexia is associated Monitor vital Reduced the risk
newmens data maternal will not patients vital signs with infection and signs. of maternal
system model : I am having infection develop an every 4 hour. warrants antibiotics. infection as
Focus is on anxiety related to infection. evidence by
prevention as regarding delivery and Assess the patient Indications of healing Use strict aseptic antibiotics
intervention. further secondary to abdomen and include no signs of technique when therapy.
Primary complication surgical abdominal dressing . redness, edema drainage. performing dressing
prevention incision. and the incision area
Secondary is assessed.
prevention. Objective
Tertiary data: Assess the Foul smelling may Monitor lochia
prevention . There is tension perineum, noting any indicate genital tract for foul smelling.
here the focus and anxiety foul smelling lochia. infection.
is on Mrs. seen in patient's
Hetal's reaction face. Asses bladder The presence of Catheter care is
to possible drainage; provide catheter contributes to the given.
complication catheter care . risk of infection.
using primary
prevention Assess for the General anesthesia Monitor breath
preventives breath sound; and voluntary immobility sound and Provide
measures the schedule coughing may result in Coughing and
looks at line of and breathing accumulation of breathing exercise is
defense and exercises after secretions. given.
resistance. administration of
analgesics.
 Theory Assessment Nursing Objective Planning Rationale Implementation Evaluation
diagnosis
Self care deficit Subjective data: Activity The patient Note the type of Spinal anesthesia Changes the Mrs. Hetal
theory by I am not able to intolerance will develop anesthetic recovery requires position every 2 activity levels is
Dorothea Orem do my daily related to minimal administered;Changes lying flat in bed in hours. increased.
on collecting activity . delivery and squeal from the position frequently. bed in the supine or
data related to secondary to inactivity and side lying position
self care deficit anesthetic will for 8-12 hour.
In this Mrs. Objective data: administrati progressively
Hetal's She looks dull, on, surgical increase. Assist the patient Deep breathing Assisted in doing
behavior and not able to incision and with deep breathing and and coughing help deep breathing and
response to do her pain. coughing every 2 to 4 clear accumulated coughing exercises.
ability to do her activities. hour. Splint the incision lung secretions.
daily activity. with a pillow or
interwined fingers.

Instruct her in leg Blood stasis in Instructed in

exercises. peripheral vessels doing leg exercise.
predisposes the
patient to
thrombophlebitis.

Assist the patient The patient with Assisted the

with progressive progressive patient in
ambulation. ambulation may ambulation.
resulting in vertigo.