Risk for Decreased Cardiac Output Risk for Decreased Cardiac Output: At risk for inadequate blood pumped by the heart to meet metabolic demands of the body. Risk factors may include  Alteration in systemic vascular resistance  Decreased venous return Possibly evidenced by  [Not applicable; presence of signs/symptoms establishes an actual diagnosis] Desired Outcomes  Patient remains normotensive, with blood loss less than 800 ml. Nursing Interventions Rationale Record length of labor, if applicable. Assess for dehydration or excess intrapartal fluid losses. Decreased intake and/or increased fluid losses lead to reduced circulating volume and cardiac output. Remove nail polish on fingernails/toes. Essential for clear visualization of nailbeds for assessing circulatory status. Check respirations, BP, and pulse before, during, and after administration of anesthesia. Hypotension is an expected side effect of regional anesthesia (e.g., epidural or spinal anesthesia) because such anesthesia relaxes smooth muscles within vascular walls, affecting circulating volume and reducing placental perfusion. Place towel or wedge under patient’s hip. Shifts uterus off inferior vena cava and increases venous return. Compression caused by obstruction of the inferior vena cava and aorta by the gravid uterus in a supine position may cause as much as a 50%decrease in cardiac output. Note shift in behavior or mental status, cyanosis of mucous membranes. Oxygen deficits are manifested first by changes in mental status, later by cyanosis. Give supplemental oxygen via mask, as indicated. Increases oxygen available for maternal and fetal uptake. Note: Nasal cannula is not recommended because of excessive oxygen loss to environment. Initiate IV infusion of electrolyte solution. Administer bolus, as indicated. Expands circulatory volume, especially prior to administration of epidural or spinal anesthesia; provides route for emergency medication in the event of a complication. Note alteration in vital signs; assist anesthetist as needed. Estimate and record blood losses. Excess fluid losses and hemorrhage during labor and the intraoperative period may reduce cardiac output and promote vasoconstriction with shunting of blood to major organs. Diminished cardiac output and shock are manifested by decreased BP, increased or thready pulse, and cool or clammy skin. Administer whole blood, plasma expanders, cryoprecipitate, platelets, or packed cells as indicated. Replaces fluid losses, increases circulating blood volume, and increases oxygencarrying capacity. Prepare and administer oxytocin (Pitocin ) infusion. Once delivery of infant and placenta is completed, Pitocin aids myometrium contraction and reduces blood loss from exposed endometrial blood vessels. Sensory/Perceptual Alterations Sensory/Perceptual Alterations: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to stimuli. May be related to     Multiple environmental stimuli Increased number of personnel Excessive noise level Psychological stress Possibly evidenced by  Exaggerated emotional response  Irritability  Muscle tension Desired Outcomes  Patient appears approprately relaxed.  Patient maintains focus, tuning out extraneous distractions.  Patient verbalizes understanding of need for increased level of activity. Nursing Interventions Rationale Examine environment Determines factors, which for factors causing sensory overload. may or may not be controllable. Cesarean birth requires many medical and nursing activities needed to ensure the health of mother and infant. Patient tends to concentrate on the procedures being performed and the conversations going on in the room. The birth experience may be compromised by invasive technology, tending to shift the focus from the birth of the infant to the surgical procedure. Give information about the surgical routine, including sounds, lights, dress, and instruments. Information about procedures, instruments, and alarms can help decrease anxiety, puts perceived “chaos” in perspective. Decrease noise levels, limit conversations, and use equipment or alarms judiciously. Patient may be keenly aware of sounds. Conversation, noise from equipment, and alarms may confuse patient or cause unnecessary anxiety. Keep eye contact, especially when wearing mask. Recognizes presence of patient or couple, conveys feeling of caring. Incorporate patient or couple in operating room conversation or Overlooking the patient can develop fear, which detracts from a positive birth silence, using concerned communication. experience. Consider eliminating additional personnel from the scene. Avoids interruption into personal space, which could increase anxiety. Individuals who are not required in care of the patient may detract from the intimacy of the birth experience. Deficient Knowledge Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic. May be related to  Lack of information  Unfamiliarity with condition  Misinterpretation Possibly evidenced by  Demand for information  Narrative misconception  False behaviors Desired Outcomes  Patient verbalizes understanding of indications for cesarean birth.  Patient recognizes this as an alternative childbirth procedure to achieve the best result possible in the end. Nursing Interventions Rationale Appraise knowledge toward the procedure. Most patients fail to retain the information instilled during childbirth classes. Therefore, patients have difficulty to remember or understand the details during the entire process. Check on the level of stress and weather procedure was planned or not. Defines patient’s or couple’s readiness to incorporate information. Give accurate information in easyto-understand terms and clarify misconceptions. Stress of the situation can affect the patient’s ability to understand information required to make informed decisions. Encourage couple to ask questions and verbalize their understanding on the matter. This provides an opportunity to assess and evaluate patient’s or couple’s understanding of the situation. Review indications necessitating alternative birth method. Cesarean birth should be viewed as an alternative and not an abnormal situation to enhance the maternal and fetal safety and well-being. Explain preoperative procedures in advance, and present rationale as Explanation of the logical reasons why a particular choice was made is vital in appropriate. preparation for the procedure. Educate patient postoperatively; including demonstration of leg exercises, proper coughing and deep breathing techniques, splinting, and abdominal tightening exercises. Provides routine to prevent complications associated with venous stasis and hypostatic pneumonia, and to lessen stress on the operative site. Abdominal tightening reduces distress associated with gas formation and abdominal distension. Further stress anticipated sensations during delivery and recovery period. Having knowledge about the possible outcomes helps prevent unnecessary anxiety. Anxiety Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response. May be related to     Perceived/Actual threat of maternal and fetal well-being Situational crisis Threat to self-concept Interpersonal transmission Possibly evidenced by  Apprehension  Distress     Feelings of inadequacy Increased tension Restlessness Sympathetic stimulation Desired Outcomes  Patient discusses feelings about cesarean birth.  Patient appears relaxed and comfortable.  Patient verbalizes fears for the safety of herself and infant. Nursing Interventions Rationale Assess psychological response to event and availability of support systems. The greater the patient perceives the threat, the greater the level of her anxiety. Consider cultural influences or expectations. Some cultures (e.g., Latin, Mexican/Arab-American) may view surgical intervention as detrimental to the patient’s wellbeing or may believe patient will be stigmatized as a “weak woman” (e.g., Puerto Rican). Know whether procedure is planned or not. If the procedure is unplanned, patient or couple usually has no time for physiological or psychological preparation. Cesarean birth can still create apprehension even if it is planned due to perceived physical threat to the mother and infant. Remain with the Helps to reduce interpersonal patient, and stay calm. Speak in a slow manner. Convey empathy. transmission anxiety, and shows caring for the patient or couple. Reinforce positive aspects of maternal and fetal condition. Focuses on likelihood of desirable outcome and helps to bring perceived or actual threat into perspective. Let the patient or couple verbalize or express inner thoughts and feelings. Helps to distinguish negative feelings and concerns as well as provides chance to cope with uncertain or unresolved feelings or grief. The patient may also feel an emotional intimidation to her self-esteem, owing to her feelings that she has failed, that she is weak as a woman, and that her expectations have not been met. Partner may question own abilities in assisting patient and providing needed support. Support/redirect expressed coping mechanisms. Improves fundamental and automatic coping mechanisms, increases selfconfidence and acceptance, and reduces anxiety. Note: Some actions by the patient may be viewed as ineffective (e.g., screaming and throwing things) and need to be redirected to enhance patient’s sense of control. Allow patient to discuss and elaborate past childbirth experience or expectations, as appropriate. Patient may have twisted thoughts of past delivery or unrealistic perceptions of abnormality of cesarean birth that will increase anxiety. Allot time for privacy. Allows patient or couple to internalize information, organize resources, and cope effectively. Risk for Situational Low Self-Esteem Risk for Situational Low Self-Esteem: At risk for developing negative perception of self-worth in response to a current situation. Risk factors may include  Perceived “failure” at a life event Possibly evidenced by  [Not applicable; presence of signs/symptoms establishes an actual diagnosis] Desired Outcomes  Patient identifies and discusses negative feelings.  Patient verbalizes confidence in herself and in her abilities. Nursing Interventions Rationale Ascertain Diagnosis of a shift in self-concept is based on knowledg patient’s unusual feelings about self and pregnancy. Note cultural influences. past perceptions and experiences. Cesarean birth, even planned or not, has the potential to change the way the feels about herself. The patient sees that the birth plan h been changed and that surgical intervention is needed t deliver the infant, while most women are able to deliver without any such intervention. Allow the patient to verbalize feelings and thoughts. Determines areas to be discussed. Patients’ feedback va may be hard to diagnose in the preoperative stage. Feel negative self-image related to disappointment in the birt experience may interfere with postpartal activities relate successful breastfeeding and infant care. Encourage questions and give facts. Reinforce previous learning. Improves understanding and clarifies misconceptions. Associate cesarean birth as an alternative method of childbirth. Terms like “C-section” and “normal delivery” may bolste patient’s thought that the cesarean birth is unusual and abnormal, and patient may look at self as inadequate, fl or weak. Provide verbal communication of assessment and interventions. Written information can be given at a later time. When a problem of self-esteem arises for the patient, it m become more critical in the postpartal period. During the preoperative period, patient is focusing on the here and and may not be ready to read or deal with additional information. Recognize other At this significant time, the view of the situation usually couples or resources to be referred situation to after delivery. not provide chance to communicate with others who hav shared the same experience. However, these activities m beneficial in the future to help with resolution of feelings perceptions. Allow partner’s presence at the delivery as desired. Provides support for the patient, encourages parental bo and gives additional input to the patient’s recall of the b experience because memory lapses are more common d periods of crisis. Note: Cultural expectations may preven support of father in birth process, necessitating attendan a female family member. Encourage the patient or couple to participate in room bonding activities (e.g., breastfeeding and holding the infant) as able. Provides reinforcement of the birth experience and deemphasizes the surgical nature of the delivery. Powerlessness Powerlessness: The lived experience of lack of control over a situation, including a perception that one’s actions do not significantly affect an outcome. May be related to  Interpersonal interaction  Perception of illness-related regimen  Lifestyle of helplessness Possibly evidenced by  Lack of participation in care of decision-making  Passivity  Verbalization of lack of control Desired Outcomes  Patient verbalizes fears and feelings of vulnerability.  Patient expresses individual needs and desires.  Patient participates in decision-making process whenever possible. Nursing Interventions Rationale Appraise circumstances contributing to sense of powerlessness. Powerlessness becomes a major stress factor for patients experiencing their first hospitalization, which includes fear of the unknown. Unplanned (and sometimes planned) cesarean birth may be characterized by the patient’s or couple’s sense of loss of control over the birth experience. Consider options in care when possible (e.g., IV placement, choice of anesthesia, and use of mirror) Allows the patient to have some sense of control over the situation. Recognize patient’s or couples expectations and desires concerning the delivery Provides opportunity to accommodate needs and encourage positive experience. experience. Allot personal time and space for the couple before the surgery, if possible. Stay with patient if partner is absent. Lets the couple talk about the situation by themselves. Leaving patient alone may result in feelings of abandonment and adds anxiety. Provide information, and talk about the patient or couple’s perceptions. Lessens stress brought by misconceptions and unfounded fear