doi: 10.62486/agmu202340
ORIGINAL
Nursing care in patients
with cesarean section due to premature rupture of membranes in the obstetrics
and gynecology service of a Lima hospital, 2022
Cuidados de enfermería
en paciente con cesárea por ruptura prematura de membranas del servicio de
gineco obstetricia de un hospital de Lima, 2022
Tania R
Alcántara-Echegaray1, Cynthia M. Gonzales-Carbajal1,
Sofía D. Vivanco-Hilario1, Wilter C. Morales-García1 
*
1Unidad
de Posgrado de Ciencias de la Salud, Universidad Peruana Unión, Escuela de
Posgrado. Lima, Perú.
Cite as:
Alcántara-Echegaray TR, Gonzales-Carbajal CM, Vivanco-Hilario SD, Morales-García
WC. Nursing
care in patients with cesarean section due to premature rupture of membranes in
the obstetrics and gynecology service of a Lima hospital, 2022. Multidisciplinar
(Montevideo). 2023; 1:40. https://doi.org/10.62486/agmu202340
Submitted: 10-06-2023
Revised: 14-09-2023 Accepted: 18-11-2023
Published: 19-11-2023
Editor: Telmo
Raúl Aveiro-Róbalo 
ABSTRACT
Premature rupture of membranes (PROM) is
defined as the loss of continuity of the amniotic membranes with transvaginal
amniotic fluid leakage, which occurs before the start of labor, where cesarean
section is the surgical medical treatment with the purpose of avoid
complications of neonatal maternal morbidity and mortality. The objective of
the study was to manage the nursing care process for a patient with a cesarean
section due to PROM. Under a qualitative approach, single case type and
methodology, the nursing care process was applied, in which the five stages of
the PAE were applied where the assessment was carried out applying Maryori
Gordon’s functional patterns assessment guide, three diagnoses were
prioritized. nursing: acute pain, risk of surgical wound infection and anxiety,
using the NANDA taxonomy. In planning, a care plan was developed considering
the NOC, NIC Taxonomy and in the execution stage, interventions were carried
out for each nursing diagnosis and the evaluation was carried out through the
differentiation of the final and baseline target score, achieving change score
+2, +2, +2. It is concluded that the PAE allows you to provide specialized care
in a comprehensive and quality manner throughout the recovery process.
Keywords:
Nursing Care Process; Post-Cesarean Section; Premature Rupture of Membranes.
RESUMEN
La ruptura prematura de
membranas (RPM) se define como la pérdida de la continuidad de las membranas
amnióticas con salida de líquido amniótico transvaginal, que se presenta antes del
inicio del trabajo de parto, donde la cesárea es el tratamiento médico
quirúrgico con la finalidad de evitar complicaciones de morbimortalidad materna
neonatal. El estudio tuvo como objetivo gestionar el proceso de cuidados de
enfermería a una paciente con cesárea por RPM. Bajo un enfoque cualitativo,
tipo caso único y de metodología el proceso de atención de enfermería, en la
que se aplicó las cinco etapas del PAE donde la valoración fue realizada
aplicando la guía de valoración de los patrones funcionales de Maryori Gordon,
se priorizaron tres diagnósticos de enfermería: dolor agudo, riesgo de
infección de la herida quirúrgica y ansiedad, utilizando la taxonomía NANDA. En
la planificación se elaboró un plan de cuidados teniendo en cuenta la Taxonomía
NOC, NIC y en la etapa de ejecución se realizaron las intervenciones para cada
diagnóstico de enfermería y la evaluación se realizó a través de la
diferenciación de la puntuación diana final y basal logrando puntuación de
cambio +2, +2, +2. Se concluye el PAE permite proporcionar cuidados
especializados de forma integral y de calidad en todo el proceso de su
recuperación.
Palabras clave:
Proceso de Atención de Enfermería; Poscesárea; Ruptura Prematura de Membranas.
INTRODUCTION
Premature
membrane rupture (PROM) is defined as the loss of continuity of amniotic
membranes with transvaginal amniotic fluid leakage that occurs before the onset
of labor (Fajardo-Mancia & Henriquez-Pereira, 2020).
Currently,
it is one of the main reasons for infectious morbidity in the mother and
neonate due to clinical, epidemiological, and nutritional factors (Borja et
al., 2019).
According
to the WHO, PROM occurs between 8 and 10 % of all pregnancies, and 60 to 95 %
correspond to pregnancies; the most infrequent are preterm PROM, with 2 to 4 %
of all pregnancies (Marquina-Reynaga, 2018). At the South American level, it is
recorded that one in eight births is preterm, with PROM as the leading cause
(Marquina-Reynaga, 2018). In the case of Latin America, it is estimated that
the incidence of PROM ranges from 5,7 % to 8,9 %, higher in Peru at 13,6 %.
(Velaña-Sinchiguano and Pico-Naranjo, 2018).
In
Peru, PROM occurs in 4 % to 18 % of all deliveries. ESSALUD reports an annual
frequency of 7 % of preterm deliveries; in MINSA, out of 1523 deliveries, 15,7
% were detected, i.e., one case of PROM for every six deliveries; in
specialized institutes, the incidence is 10,1 % of deliveries (Meléndez-Falcón,
2021a). (Meléndez-Falcón, 2021a).
PROM
is the spontaneous rupture of the chorioamnionitis membranes that occurs before
the onset of labor. In gestation, after 22 weeks, it is considered when it
lasts more than 24 hours. There are two categories: a term that occurs after 37
weeks of gestation and preterm before 37 weeks of gestation (Vásquez-Coello et
al., 2021).
PROM
refers to the rupture of the membranes before the onset of labor; if this
happens before 37 weeks of gestational age, it is called preterm premature
rupture of membranes (PROM). (Monge, 2017). PROM is defined as the loss of continuity
of the chorioamnionitis membranes occurs with amniotic fluid leakage lasting
more than one hour prior to the onset of labor (Amaya et al., 2015).
The
causes of PROM are varied, with the following risk factors: cervical
incompetence, use of cerclage, tobacco use, history of preterm delivery, and/or
rupture of membranes in previous pregnancies (Meléndez-Falcón, 2021b). Also, it
varies with gestational age; if the rupture occurs at a lower gestational age,
it is associated with infection of the chorion, and otherwise, it is associated
with decreased collagen content in the membranes; this may also be secondary to
some microorganisms that produce collagenases, mucinases and proteases
(Velaña-Sinchiguano & Pico-Naranjo, 2018).(Velaña-Sinchiguano & Pico-Naranjo,
2018).
Risk
factors for PROM include genital tract infections, intrauterine infections
(bacterial vaginitis, trichomonas, gonorrhea, chlamydia), antepartum
hemorrhage, multiple pregnancies, polyhydramnios, cervical isthmic
incompetence, low vitamin C and E supplements, substance abuse, smoking,
nutritional status, low socioeconomic status, and sexual intercourse (Orias
Vásquez, 2020).
Likewise,
PROM presents a physiological weakening of the membranes caused by the decrease
in their resistance caused by the poor deposit of collagen II and edematization
due to the deposit of fibrinoid material. This causes a thinning of the
trophoblastic and decidual layers; the decidual cells produce hormones
(prostaglandins E2 and F2) to initiate (induce) labor, favoring contractions.
(Orias Vásquez, 2020).
The
clinical picture of PROM is supported by the presence of signs and symptoms,
clinical history, and diagnostic tests such as spectroscopy: visualization of
amniotic fluid outflow by Valsalva maneuver, atrazine test: based on
differentiating the pH of amniotic fluid that is alkaline with other secretions
(vaginal) and urine; fern test positive to the amniotic fluid, finding a
pattern of arborization in the slide when dried to the environment by sodium
chloride; ultrasound scans detect whether there is oligohydramnios or
hydramnios, the normal value of amniotic fluid is 3,7 cm (Vásquez-Coello et
al., 2021).
The treatment of PROM depends on fetal
maturity; in term PROM greater than 37 weeks of gestation, labor is induced,
and in preterm PROM before 37 weeks of gestation, the treatment is with
antibiotics and corticosteroids for pulmonary maturity, and finally, in PROM
with less than 23 weeks of gestation is considered non-viable pregnancy.(Orias
Vásquez, 2020); also includes the inhibition of contractions, the use of
antibiotics to prevent infections, and the injection of glucocorticoids to
promote pulmonary maturation. However, approximately 90 % of pregnant women
deliver within one week (Meléndez-Falcón, 2021c).
The nursing care process (PAE) is
important because it allows us to apply the scientific method in each stage and
provide specialized care to the patient and family. This methodology allows us
to provide care to patients systematically, logically, orderly, and with
favorable results. Therefore, performing a complete, objective, and accurate
nursing assessment is of utmost importance since it is the basis for
identifying the relevant nursing diagnoses. The EAP comprises five stages:
assessment, diagnosis, planning, execution, and evaluation, as well as
interrelated, feedback, and successive (Miranda-Limachi et al., 2019).
The nursing professional specialist in
gynecometrics is part of the multidisciplinary health team. She is highly
trained to care for post-cesarean patients since she has the necessary
knowledge to provide comprehensive care by guiding, teaching, and providing
timely solutions to help achieve the patient's recovery and preserve life.
(Valarezo, 2018).
METHOD
The study uses a qualitative approach, a
single clinical case study type, and the nursing care process (PAE), a
scientific method for identifying the patient's health problems, supported and
justified with scientific evidence. Therefore, it is necessary that research is
developed to contribute to the fundamentals and provide quality and warmth in
care. (Castro and Simian, 2018).
The study subject was a 35-year-old
woman, selected at the convenience of the researchers, with a medical diagnosis
of postoperative cesarean section due to PROM of 48 hours, with a gestation
period of 32 4/7 weeks, with a urinary tract infection under treatment, and an
elderly mother. The study was carried out in a hospital in Callao (Lima).
Information was collected through interview, observation, and physical
examination; it was then organized using a guide based on Marjory Gordon's
functional pattern assessment framework, identifying nine altered nursing
diagnoses, prioritizing three diagnoses: Acute pain, risk of infection, and
anxiety, based on the NANDA Taxonomy 2021 - 2023 and the care planning was
developed based on the NOC and NIC taxonomy, with which the corresponding care
was elaborated in the execution stage, allowing the evaluation of the results
according to the differentiation of the basal target score with the final
score.
NURSING CARE
PROCESS
Valuation
General Data
·
Name: C. C. P.
·
Age: 35 years old
·
Service: gynecology hospitalization
·
Medical
diagnosis: Post-operated three-hour cesarean section due to 48-hour PROM, with
gestation of 32 4/7 weeks, urinary tract infection, aged, with an
inter-gestational period of 8 years.
·
Days of hospitalization: First day
·
Valuation date: 04/10/2022
·
Hours of operation: 12 hours
Reason
for admission
The patient is received from the
recovery room with three hours of immediate postoperative period for cesarean
section, transferred on a stretcher by the nurse and nursing technician, the
patient is awake, oriented in time, space and person; pale facies, ventilating
spontaneously, moaning, referring pain in the operative area, asking about the
health of her baby, hospitalized with immediate poscesarean medical diagnosis for
premature rupture of membranes of 48 hours and urinary tract infection (UTI).
Assessment according to Functional Health Patterns
Functional Pattern I: Perception
- Control of Health. She denies any relevant history of diseases.
She presents a surgical history of a cesarean section 8 years ago and an
obstetric history of RPM of 48 hours. She denies blood transfusions, drug or
food allergies, does not consume drugs, alcohol, or tobacco, and has good
hygiene. She received only one dose of the tetanus vaccine. She did not have
COVID-19 disease and has two SRs COVID-19 vaccinations, with a current COVID-19
antigen test result that is not reactive.
Functional pattern II:
Nutritional metabolic. Current weight of 68 kg, height 1,62 cm, with a normal
gestational BMI of 25,95 kg/m2, with a body temperature of 37,0° C, usual
glucose dosage of 82 mg/dl, with results of preoperative hemoglobin lab
results: 10,4 g/dL considered mild anemia grade I, and postoperative hemoglobin
of 8,56 g/dL considered moderate anemia grade II. Presents warm, pale, intact
skin, with signs of dehydration due to the skin and oral mucosa not being very
moist, good oral hygiene, and complete dentition.
Patient on postoperative gastric rest,
no nausea or vomiting, soft, depressible, globular, and painful abdomen;
presence of suprapubic operative wound (Pfannenstiel laparotomy); covered with
clean and dry dressings; no weight loss in recent months; maintaining his
appetite.
Functional pattern III: Elimination.
Patient has not passed stool for 4 days, presents permeable bladder
catheter with clear urine and leukocytes of 29 per field, considered pathological.
Functional Pattern IV: Activity - Exercise. Respiratory activity:
Patient presents 20 breaths per minute,
ventilating spontaneously without alterations, with an oxygen saturation of 98
%, no cough, no secretions, no respiratory sounds. Circulatory Activity: 102 heartbeats per minute, blood pressure: 90/50 mmHg,
with tendency to hypotension, no edema in upper and lower limbs, peripheral
catheter located in right upper limb, receiving parenteral fluids, sodium
chloride 9 per 1000 plus oxytocin 30 IU at a drip of 45 drops per minute. Activity Self-care capacity: Remains at absolute rest for three hours
post-cesarean, preserved limb mobility, decreased muscle strength and weakness.
Functional pattern V: Rest
- sleep. Patient did not fall asleep for three hours due to the
presence of pain in the operative area and concern for the health of her
newborn, during the interview the patient reported that she slept at intervals
and did not get a restful rest, she denied the use of drugs to sleep.
Functional pattern VI: Perceptive
- Cognitive. On observation oriented in time, space and person,
with a Glasgow scale of 15 points, no abnormalities of hearing, vision, speech
and language. Patient reports pain in the operative wound with a pain scale
(VAS) of 7 points, pain expression facies and complaining attitude.
Functional Pattern VII: Self-perception
- Self-concept. Patient refers: "that she was not ready to
have her baby, after such a long time, but I waited for it with great
enthusiasm", she is anxious and fearful, worried about her current state
of health and that of her baby.
Functional
pattern VIII: Role-relationships. Patient
is a housewife, 5th grade of high school, married, lives with her husband and
her son, with a nuclear family structure, has the support of family and
friends, does not report domestic violence and has not presented suicide
attempts.
Functional pattern IX: Sexuality/Reproduction.
Refers to menarche at 12 years of age. Onset of sexual activity: 20
years old, with three sexual partners, using contraceptive methods such as
condoms and intrauterine device (IUD). Obstetric history: gestations (2),
abortions (0), vaginal deliveries (0), cesarean section (1). The gestation was
32,4/7 weeks and six prenatal controls. Last menstrual period: January 3, 2022,
with probable due date: November 10, 2022.
Postoperative cesarean section due to
amniotic fluid leakage (PROM) for 48 hours; physical examination showed soft
breasts, free of signs of inflammation, with formed nipples, no palpable lumps,
scarce colostrum secretion, and uterus contracted at the scar level. The
umbilical cord, presence of hematic lochia without foul odor in moderate
quantity, approximately 100 ccs on uterine massage, genitalia without
alterations, no edema. Female newborn with Apgar of 8' 8'.
Functional Pattern X:
Adaptation - Situation and Stress Tolerance. The patient reports being worried
about her baby's health; it is her second baby after 8 years, and she has not
seen him since the operating room; she and her husband are agitated about the
baby's health; she also says that all her family supports them constantly. She
denies taking anxiolytics and antidepressants.
Functional Pattern XI: Values
- Beliefs. Catholic, non-practicing.
Nursing Diagnosis
First Diagnosis
·
Diagnostic label: Acute Pain (00132)
·
Related
factor: Physical injury agent secondary to operative wounds, injuries.
·
Defining
characteristics: verbal report of pain according to VAS scale: 7 points, pain
expression facies and complaining attitude.
·
Diagnostic
statement: Acute pain related to physical injury agent secondary to surgical
wound, pain evidenced by verbal report of pain according to VAS scale: 7
points, pain expression facies and complaining attitude.
Second Diagnosis
·
Diagnostic
Label: Risk of Surgical Wound Infection (00266)
·
Associated
condition: Surgical procedure and invasive procedures
·
Diagnostic
Statement: Risk of surgical wound infection evidenced by surgical procedure and
invasive procedures.
Third Diagnosis
·
Diagnostic label: Anxiety (00146)
·
Related
factor: Unknown health status of the newborn.
·
Defining
characteristics: Expression of concern for the health of her newborn (premature).
·
Diagnostic
statement: Anxiety as evidenced by expression concern for her newborn's health.
Planning
First Diagnosis. Acute pain.
Nursing Outcomes. NOC
[2102] Pain level.
Indicators
·
Referred pain.
·
Facial expression of pain.
·
Grimaces of pain.
Nursing Interventions.
NIC [1410] Acute pain management.
Activities
·
Perform
a comprehensive assessment of pain: location, duration and intensity.
·
Identify
pain intensity during movement during recovery
activities.
·
Monitor
pain using a valid measurement tool.
·
Review
the medical indications of the prescribed analgesic, dosage and frequency.
·
Administer
metamizole 2 gr EV every 8 hours and tramadol 50 mg SC PRN severe pain
·
Evaluate
the efficacy of analgesics at regular intervals after each administration.
Second Diagnosis. Risk of surgical wound infection.
Nursing Outcomes. NOC
[1908] Risk Detection.
Indicators
·
Recognize
signs and symptoms that indicate risks.
·
Identify potential health risks.
Nursing interventions.
NIC [6550] Protection against infection.
Activities
·
Observe
for signs and symptoms of systemic and localized
infection.
·
Observe
the patient's vulnerability to infection.
·
Monitor
white blood cell count and white blood cell formula
·
Inspect
the condition of the surgical wound
·
Follow
the ten rules of proper management of management
·
Administer
intravenous antibiotic medication: Clindamycin 900 mg every 8 hours and
gentamicin 160 mg every 24 hours.
Third Diagnosis.
Anxiety.
Nursing Outcomes. NOC
[1302] Coping with problems.
Indicators
·
Verbalizes
acceptance of the situation.
·
He
reports decrease in negative feelings.
·
Uses effective
coping strategies.
Nursing Interventions.
NIC [5270] Emotional support.
Activities
·
Help
the patient recognize feelings such as anxiety, fear or sadness.
·
Encourage
the patient express feelings of anxiety, fear or sadness.
Table 6 shows that the mode of the
selected problem coping outcome indicators for the diagnosis of anxiety, the
baseline score before nursing interventions was 2 (rarely demonstrated), after
the application nursing interventions the mode 4 (frequently demonstrated),
evidenced by acceptance of their situation, refer better favorable feeling and
expresses favorable feelings, achieving a change score of +2.
RESULTS
The
assessment was carried out by collecting data from the patient as the primary
source and the clinical history as a secondary source. The physical examination
was used as a means of data collection, and then the information was organized
using Marjory Gordon's functional health patterns assessment guide.
For
the diagnosis, an analysis of significant data according to NANDA (2021-2023)
was performed. Nine nursing diagnoses were identified, of which three were
prioritized: acute pain, risk of surgical wound infection, and anxiety.
The
planning phase considered the NOC and NIC taxonomies so that the nursing
diagnoses and interventions are consistent with the results.
For
the execution stage, interventions are carried out promptly and efficiently
during the care provided.
Finally,
the evaluation phase allowed comparing the baseline score with the final score,
achieving for each outcome the change score of +2, +2 and +2.
DISCUSSION
Acute Pain
Pain is an unpleasant sensory and
emotional experience associated with actual or potential tissue injury (Perez
& Perez, 2018).
The above definition agrees with other
authors in referring to acute pain as an unpleasant sensory and emotional
experience occasioned by actual or potential tissue damage or described in
terms of such damage, of sudden or slow onset, of any intensity from mild to
severe with an anticipated or predictable end, lasting less than three months
(Herdman et al., 2021a).
Postoperative pain is caused by multiple
lesions in the anatomical structure, comprising an acute and noxious discomfort
that lasts from 1 to 7 days, and its intensity can vary from nonexistent to
unbearable; this will depend on a variety of factors, such as biological
injurious agents (infection, ischemia, cancer, etc.), physical injurious agents
(abscess, amputation, burn, cut, surgical processes, etc.) and chemical
injurious agents (Herdman et al., 2021b).
Surgical pain is produced by the
manipulations involved in the surgical procedure when allogenic substances that
cause pain are released from the organism and when there is trauma. A signal is
sent to the central nervous system through the spinal cord, causing repercussions
at the cardiovascular, gastrointestinal, and nervous system levels (Carvalho et
al., 2017a).
According to the American Society of
Anesthesiologists (ASA), postoperative pain is pain that is present in the
patient due to the disease, surgical procedure, and its complications, or a
combination of both. It is fundamentally characterized as acute, time-limited,
predictable, and avoidable pain. (Pérez-Guerrero et al., 2017)
According to the visual analog pain
scale (VAS), pain is classified as mild pain (less than 3), moderate pain
(between 4 to 7), and severe pain (greater than 8). (Vicente Herrero et al.,
2018)
Postoperative pain occurs as a result of
a surgical procedure; 90 % of patients present with postoperative pain, and
approximately 60 % suffer moderate to severe pain in their first 24 hours
post-surgery (Huayanay et al., 2023).
In our study, the patient presents pain
on a VAS scale of 7 points, with defining characteristics of facial expression
of pain and complaining attitude due to having undergone a surgical procedure
such as cesarean section, which is a surgical intervention that produces
postoperative pain that comes from the injury to the abdominal wall for the
extraction of the fetus and uterine involution (intussusception). (Carvalho et
al., 2017b).
Acute pain is related to physical injury
as a consequence of the surgical intervention that results in an aseptic wound,
which requires essential nursing care oriented to pain management with
pharmacological techniques (Aguilar, 2022).
Surgical pain is caused by the
manipulations involved in the surgical act when allogenic substances are
released from the organism. When there is trauma, a signal is emitted to the
central nervous system through the spinal cord, causing repercussions at the
cardiovascular, gastrointestinal, and nervous system levels (Carvalho et al.,
2017c).
The nursing intervention for acute pain
management was considered, and the following activities were performed:
Assessment of pain intensity according to the VAS scale: To evaluate the analog
scale, a 10-centimeter line is used. At one end, the phrase "no pain"
is used, and at the other end, the worst pain imaginable is used. The signal
made by the patient between the two extremes indicates the magnitude of the
pain. This instrument is valid, reliable, and understandable.
The patient must have motor and visual
coordination. A value lower than 4 is mild-moderate VAS, from 4 to 6 is
moderate-severe, and a value higher than 6 is severe pain. Pain provokes a
sympathetic stimulus that can be associated with arterial hypertension,
tachycardia, sweating, and tearing. (Vicente et al., 2018).
Another intervention is to monitor vital
functions such as heart rate, respiratory rate, and blood pressure. Vital signs
indicate the patient's health; their variation changes physiological
functioning. Changes in vital signs such as tachycardia, hypertension, and
increased respiration often indicate acute pain and discomfort. Vital signs
represent a quick and effective method of identifying problems; therefore, a
frequency in their measurement is established (Potter, 2019).
Another care was to administer
metamizole two grams, intravenous every eight hours, a drug that inhibits the
action of cyclooxygenase, consequently, the synthesis of prostaglandins; this
action explains its analgesic and antipyretic properties; however, the patient
under study presented a VAS of seven points so tramadol 100 mg subcutaneous was
administered, a non-steroidal anti-inflammatory agent that binds to gamma
opioid receptors in the central nervous system and acts on the perception of
severe pain. (Vademecum, 2018).
Surgical Wound
Infection Risk
The risk of surgical wound infection is
defined as being susceptible to an invasion of pathogenic organisms at the
surgical site, which may compromise health, according to (Herdman et al., 2021)
At the beginning of an infectious
process, an entrance door is needed so that the microorganisms can enter the
tissues; this can occur through an invasive surgical procedure, which is a surgical
incision.
An infection can develop depending on
the germ's degree of virulence, local response, and host immune response
(Romero Alvarado, 2017).
Risk factors such as PROM, emergency
cesarean section, and number of vaginal tracts in a patient undergoing cesarean
section make predict possible complications, and prevention during previous
procedures is important. (Chávez Marín, 2019).
Within the nursing intervention, the
following activities were considered: Protection against infections, with the
following activities:
Observe signs and symptoms of systemic
and localized infection: operative wound infections usually occur after 48
hours, and local signs of pain, edema, heat, erythematous skin change, and
purulent drainage are observed. Some may develop fever (Chávez Marín, 2019).
Another intervention was to monitor
vital functions: they indicated that infection increases temperature and
cardiac output due to increased metabolism and vasodilation (Guyton et al.,
2021). Also, signs and symptoms indicating wound infection include tachycardia,
increased temperature, and pain palpation. (Smeltzer et al., 2019).
Infection occurs from the fifth day of
discharge, hence the importance of teaching the patient about wound care (local
temperature rise, incisional pain, and wound oozing). (Smeltzer et al., 2019)
The patient's vital functions were
monitored periodically, which allowed the quick and effective detection of any
alteration and avoided further complications (Potter, 2019).
Another intervention is to monitor
operative wound dressings: early recognition of slow healing or the development
of complications can prevent a serious situation (Briseño et al., 2019).
Operative wound dressings should be removed by 24 hours after cesarean section,
evaluate signs of infection in the wound for increased pain, redness,
discharge, and dehiscence, suggest loose clothing and cotton, and clean and dry
the wound gently. Among other infection-preventive activities are dressings,
dressing changes, observation of skin changes, and vital functions on an
ongoing basis. Wound healing is performed to diminish or eradicate the
proliferation of microorganisms and skin recovery.
Another activity is to monitor the
patient's white blood cell count: The hemogram is one of the most widely used
diagnostic tests that allow determining with a high degree of reliability,
speed, and a low cost the main hematological parameters in peripheral blood,
providing valuable information about the three thematic series (red blood
cells, white blood cells, and platelets), which allows detecting morphological
alterations that indicate infection (Huerta Aragonés & Cela de Julián,
2018).
The WHO recommends strategies to reduce
maternal infections through prophylaxis and appropriate antibiotic treatment,
as well as establishing an international standard for cesarean deliveries,
which should only be 15 % of registered deliveries; however, this figure has
been increasing in recent years (WHO, 2019).
Clinical hand washing before and after
each procedure favors the elimination of pathogenic microorganisms; the
antiseptic solution used must comply with the bactericidal or bacteriostatic
principle. (Potter, 2019)
The insertion of a urinary catheter in
patients undergoing cesarean section facilitates the entry of germs into the
urinary tract; to reduce the risk of infection, the bladder should be kept
empty and removed immediately in the postoperative period (Huamán et al.,
2019).
On the other hand, another risk of
infection is invasive devices such as peripheral catheters, which are directly
in the bloodstream, where gram-positive bacteria are of greater affection in
patients (Garay, 2017).
Peripheral catheter recanalization every
three days or according to protocol decreases the direct risk of pathogens
entering the bloodstream and phlebitis (Brunner et al., 1994).
Another care is administering
antibiotics, according to medical prescription, clindamycin 900 mg every 8
hours and gentamicin 160 mg every 24 hours.; they are widely used in these
cases as they are bactericides used as a prophylactic means of infections, of
mandatory use in the postoperative period due to rupture of the main protective
layer, the skin (Vademecum, 2018). The use of antibiotics is mandatory in
patients with risk factors such as puerperal endometritis, the most frequent
ones being premature rupture of membranes, prolonged labor, repetitive vaginal
examinations, anemia, and obesity (Huamán et al., 2019).
Anxiety
Anxiety is defined as a feeling of
apprehension, uneasiness, exhaustion, insecurity, and fear, which occurs in
anticipation of a threat, where anxiety reactions vary from patient to patient
and from phase to phase in the sufferer's behavior (Potter, 2019).
Another definition mentions that anxiety
is an emotional response to a diffuse threat in which the individual
anticipates an unspecific imminent danger, catastrophe, or misfortune, and
usually the origin of the anxiety is often unspecific or unknown to the person
in anticipation of imminent danger and allows the person to take action to cope
with the threat (Herdman et al., 2021).
Anxiety levels may remain elevated in
the immediate postoperative period due to pain, the hospital environment,
feeling unable to control circumstances, fear of the effect of surgery, fear of
complications, loss inability to care for oneself, fatigue, spiritual distress,
altered roles and responsibilities, poor coping and altered body image (Brunner
et al., 2017).
Faced with an external event such as
surgery, anxiety impacts psychically as well as physically because there is
concern about independence, pain, physical conditions, recovery, separation
from members, hospitalization, and hospital stay. Likewise, it is accompanied
by physiological symptoms that may persist after surgery, such as elevated
blood pressure, tachycardia, arrhythmia, and dyspnea, affecting the recovery of
the postoperative patient. (Torres, 2018).
The anxiety that is generated in the
mother in the puerperium stage occurs because anatomical and physiological
changes occur because they feel lonely after childbirth since the attention is
focused on the newborn (Cunningham et al., 2018).
Anxiety causes an increase in
sympathetic nervous system activity, altering cardiovascular symptoms, causing
hypertension, elevated heart rate, shortness of breath, palpitations, and
tachypnea. Therefore, nursing intervention focuses on identifying and
decreasing the level of anxiety and improving coping with it. (Butcher et al.,
2018).
One of the defining characteristics of
anxiety is the expression of concern for the health of their newborn
(premature), a very stressful situation for the patient since it means facing
an unexpected reality in which their expectations about the experience of
pregnancy and normal childbirth are lost. In addition, they will have to face
not only the initial separation.
Of their child, but also the loss of
their maternal role, as care will be assumed in the neonatal unit; for all
these reasons, during the puerperium, these women will be especially vulnerable
to mental health problems. They will be more at risk of suffering high levels
of anxiety, depression, and even post-traumatic stress symptoms (Salut et al.,
2018).
The unknown situation of the newborn's
health is related to the birth of a baby with some pathology and/or
prematurity; it is a painful and stressful situation that can affect the
emotional state of the mother, increasing her feeling of uncertainty and worry.
Indeed, anguish and fear of death appear as a constant threat to the baby. On
the other hand, several studies agree that the hospitalization of a critically
ill newborn causes a high degree of anxiety; the most significant challenge for
mothers is to adapt to this circumstance to avoid altering the mother-child
bond (Sanguesa, 2020).
Nursing Intervention: Emotional Support
was considered, and the following activities were implemented:
It is important to emphasize that family
and healthcare staff support helps manage the stressor event and/or anxious
state during the patient's postoperative process. Emotional support, through
active listening and timely information about the treatment and her disease
process, reduces levels of anxiety, fear, and pain perception (Moorhead et al.,
2018d).
Likewise, creating an environment of
trust between the nurse and the patient. Generating an atmosphere of empathy
where trust prevails will be significant in providing adequate care to the
patient, considering that trust has to be a reciprocal process between the
nurse and the patient (Vargas et al., 2020).
On the other hand, the patient is
encouraged to express their feelings, perceptions, and fears, as that is very
positive, through facial, vocal, non-linguistic, and postural expressions,
helping them to improve their mood (Clares, 2018).
Another intervention is to facilitate
the use of prayer, which is part of spiritual care that involves an
interpersonal relationship between the nurse and the patient, which seeks to
provide comfort and relief and admits personal spiritual practices such as
praying, reading sacred literature, or receiving a spiritual leader (Torrecilla
and Malagón, 2023).
CONCLUSIONS
The Nursing Care Process (PAE) allowed
for the identification of the real and potential needs of post-operative
cesarean section patients with premature membrane rupture. For this, a
specialized, individualized, and comprehensive care plan was developed for the
prompt recovery of the health problem. Thus, it is an excellent methodology for
providing care in a systematic, logical, and orderly manner with favorable
results.
It is important that the nursing
professional has knowledge of the pathologies involved in the care he/she
provides; this knowledge empowers the professional and allows him/her to act
immediately and timely when the need arises. In health problems with a risk of
complication, care should be based on permanent monitoring and prevention to
avoid situations that put health at risk.
It is concluded that to obtain nursing
results and interventions, the correct identification of nursing diagnoses is
fundamental, as well as the nursing professional's management of the
NANDA-NOC-NIC interrelationship, which will allow the use of a unified language
that facilitates nursing work.
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FINANCING
The authors received no funding for the
development of this research.
CONFLICT OF INTEREST
The authors declare that there is no
conflict of interest.
AUTHORSHIP CONTRIBUTION
Conceptualization:
Tania R Alcántara-Echegaray, Cynthia M. Gonzales-Carbajal, Sofía D.
Vivanco-Hilario, Wilter C. Morales-García.
Data curation:
Tania R Alcántara-Echegaray, Cynthia M. Gonzales-Carbajal, Sofía D.
Vivanco-Hilario, Wilter C. Morales-García.
Research:
Tania R Alcántara-Echegaray, Cynthia M. Gonzales-Carbajal, Sofía D.
Vivanco-Hilario, Wilter C. Morales-García.
Writing - original draft:
Tania R Alcántara-Echegaray, Cynthia M. Gonzales-Carbajal, Sofía D.
Vivanco-Hilario, Wilter C. Morales-García.
Writing - revision and editing:
Tania R Alcántara-Echegaray, Cynthia M. Gonzales-Carbajal, Sofía D.
Vivanco-Hilario, Wilter C. Morales-García.