help please...deperate for OB nursing diagnosisRegister Today!
This is a discussion on help please...deperate for OB nursing diagnosis in General Nursing Student, part of Nursing Student ... I am having the hardest time finding nursing diagnosis and interventions for my OB careplan. I have...by tannylp74 Apr 8, '08I am having the hardest time finding nursing diagnosis and interventions for my OB careplan. I have looked in my OB book and everything...please does anyone know a website that will give me nursing diagnosis plus the interventions.
Desperately needing help
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- Apr 8, '08 by RN BSN 2009Hi.
Could you give us some background on your patient? Subjective and objective information? That can help gear you towards the right direction.
- Apr 8, '08 by AbishagI think one Dx would be pregnancy.
j/k Please don't be mad at my joke. I really am waiting to hear details. I am really interested in this field and want to see if I could help. :heartbeat
- Apr 8, '08 by ffweste1. Pain related to the effects of uterine contractions
- nurse will teach the patient simple breathing and relaxation techniques to help with pain prior to labor.
- the nurse will assist the patient into changning positions such as standing or sitting or leaning forward, over the back of bed, side-lying, or on hands and knees every half hour or when the patient feels the need to change position
- the nurse will encourage the patient to void q1-2 hrs to decrease discomfort
- the nurse will monitor pain experienced by patient on pain scale q 1-2 hrs
- the nurse will educate the pt on progression of labor, including what to expect during the active labor process and the different stages of dilation process.
2. Ineffective individual coping related to unfamiliar or stressful environment
- identify the patient's understanding and beliefs the experience
- identify and respect the patient's coping mechanism
- assess availible/ useful past & present coping mechanisms
- analyze resources and support systems avail to patient
- assess level of understanding and readiness to learn needed lifestyle changes
3. Knowledge deficit : breathing techniques
- assess the willingness of the patient to learn effective breathing techniques before teaching
- in stage 1 of labor begin with first stage breathing which involves teaching her to take cleansing breaths before and after a contraction. Tell her to inhale and exhale in comfortable way (through mouth or nose) until these breaths do not relax her.
- if cleansing breaths are not effective, teach slow paced breathing during stage 1 of labor teach slow paced breathing during stage 1 of labor until this is not relaxing.
- when slow paced breathing is not effective, teach modified paced breathing during stage 1 of labor until these do not relax her.
- if the woman wants to focus on the pattern or number of breaths, teach patterned paced breathing
= teach second stage breathing during the pushing stage of labor.
4. Anxiety related to unknown events of labor or lack of support.
- Encourage enrollment in childbirth classes and tour hospital/birth centered
- suggest a birth plan written by client that is amenable to the specific care setting and reflects cultural expectations
- teach clients to practice proper breathing techniques for decreasing pain perception
- encourage client to enlist a labor partner
- teach the client nonpharmalogical methods of pain management
~ There is also risk for infection for mother
- Apr 8, '08 by tannylp74she was 37 weeks gestation came in for SROM. Started on oxytocin 12 hours after SROM, later given stadol and epidural. Pushed for 2 hours and was completely exhausted. Baby's heart rate was increasing and had to do emergency c-section which the nurse had to push the baby back up while doctors pulled him out.
- Apr 8, '08 by ffwesteGiven that information....
Risk for fetal injury related to decreased placental perfusion
- obtain baseline FHR electronically or manually. Also assess variability.
- position the client sidelying making sure to avoid supine
- turn off oxytocin when infusing plain IV solution, increase NS IV rate.
- administer O2 by face mask
- Initiate continuous fetal monitoring using internal devices.
Risk for maternal infection r/t invasive procedures
- the nurse will administer pain medicine to the client as prescribed by the dr
- the nurse will assist the client to turn, cough, and deep breath q2hrs while awake
- the nurse will place anti-embolism stockings or SCDs while the woman is on bedrest
- the nurse will monitor respirations on the client who had an epidural or spinal opioids q2 for the 1st 24 hrs.
- Teach the client to perform pelvic lifts lying supine with her knees bent repeating 10 times, 6 times per day.
- Teach the client not to drink carbonated beverages and avoid the use of straws.
- Apr 8, '08 by Daytoniteyou must follow the steps of the nursing process when writing a care plan.
- assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions/procedures that have been done to learn about the signs and symptoms and pathophysiology)
- determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
complications of general anesthesia include the following. some of these can be potential nursing problems. patients are kept in the hospital after surgery to monitor them for potential problems as a result of anesthesia and surgery:
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection)
- fluid and electrolyte imbalances
- urinary retention
- surgical pain
- nausea/vomiting (paralytic ileus)
- rash around the epidural injection site
- nausea and vomiting from the opiates administered
- pruritis of the face and neck caused by some epidural narcotics
- respiratory depression up to 24 hours after the epidural
- cerebrospinal fluid leakage and spinal headache from accidental dural puncture
- sensory problems in the lower extremities
every nursing diagnosis has a set of symptoms. nanda has very obligingly created a taxonomy that lists the symptoms (nanda calls them defining characteristics) for each of the current 188 nursing diagnoses. when you are first working with nursing diagnoses you should use some sort of nursing diagnosis reference to help you in finding and classifying a patient with nursing diagnoses. there are several ways to get this information.
- your instructors might have given it to you.
- you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
- many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
- there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
in the same vein, your nursing interventions are based upon those same symptoms that your nursing diagnosis is based on. those symptoms are the evidence that support the problem, or nursing diagnosis. without them there would be no problem, would there? so, isn't it logical that your nursing care efforts are aimed at these symptoms? your interventions will be to
- assess/monitor/evaluate/observe (to evaluate the patient's condition)
- care/perform/provide/assist (performing actual patient care)
- teach/educate/instruct/supervise (educating patient or caregiver)
- manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
- improve the patient's condition
- stabilize the patient's condition
- support the deterioration of the patient's condition
- Apr 8, '08 by AliveTodayKnowledge deficit always applies!
- Apr 9, '08 by futurecnmQuote from tannylp74I am having the hardest time finding nursing diagnosis and interventions for my OB careplan. I have looked in my OB book and everything...please does anyone know a website that will give me nursing diagnosis plus the interventions.
Desperately needing help
It really depends on your patient. Is this post partum or L&D?
Readiness for enhanced knowledge regarding...
Pain (if c-section etc)
Risk for infection (we can't use this one but everyone is right?)
There are some breastfeeding dx
- May 24, '09 by cleo777I have a postpartum patient, had a epidural, however she has some numbness and tingling in her lower extremeties, spoke with dr he said it will go away it is a side effect of the epidural...my question, I need Nursing Diagnosis for OB postpartum
It has not affected her mobility, but can I use this as a Nursing Diagnosis...
If so ...please help me write it!!!
It is classified as a neuro issue?