case study/Nursing diagnosis need 6

[logcrew7]

Pre-existing condition: breastfeeding toddler while pregnant

Co-existing condition: Advanced maternal age; uncertain dates; infectious work environment; exposure to fifth disease

Prioritization: Breastfeeding; family dynamics

lily is a 36y/o G2P1001, MWF. her last child, Katie is 18 months old and is still nursing at night. Lilly is a certified day care worker in the toddler room at the local YMCA. She loves the job because it means she can be close to her daughter who is in the room next door. Her husband owns his own landscaping business and enjoys working outdoors. between them they make a comfortable living. they were just married three years ago and are pleased about this pregnancy since they want several children and feel they got a late start. their first daughter was delivered at the birth center. they were both very pleased with her birth and the care they received.

Today is Lilly's first prenatal visit to the birth center with this pregnancy. Her husband and daughter accompany her. The nurse finds them in the waiting room going thru the centers picture album. they find their picture from their daughter's birth and attempt to get Katie's interest. she briefly looks at it but is more interested in the toys in the children's corner. however, despite Katie's lack of interest, it is clear to the nurse that Lilly and her husband are enjoying reliving the experience through the pictures. after a brief discussion with Lilly and her husband, Lilly goes with the nurse to one of the exam rooms while her husband stays with Katie, who is busy with a set of blocks. the nurse begins Lilly's care by asking for information to establish her due date.

[JustBeachyNurse, LPN]

this was the scenario that was given, and I have to come up with 6 diagnosis off the information given. very generic information and no assessment which is making it difficult. so the only thing I could come up with is to base it off the pregnancy and current breastfeeding.

You cannot properly do nursing diagnosis or a care plan utilizing this scenario without assessment data. There is no way to justify or "prove" a nursing diagnosis without data. It's an impossible assignment to do correctly or accurately. Pregnancy is not a nursing diagnosis.

[Beautiful Mind RN]

There are several possibilities that you can look into. Don't limit your assessment/nursing diagnoses to just the mother. Look at the father, the child (look into the different stages of child development, such as Piaget and Erikson. As well as, is the current couple's child meeting development mile stones?) Remember, nurses look at the entire picture, not just the patient who is being treated.

Hope that will kickstart your brain.

[Here.I.Stand, BSN, RN]

You should print off this thread and show it to the instructor who gave the assignment. Beautiful Mind is correct that you *could* include family nursing dx...I mean you could make a couple of wellness dx with the couple happily remembering their first pregnancy. Just based on this alone, lack of interest in this thing called "baby" is entirely appropriate for an 18 m/o. But otherwise there isn't much assessment data there either.

I'm not sure what you could say about the breastfeeding b/c the only data is that she's doing it. No nursing diagnosis to be made (breastfeeding is not a NDx), no related factor, no as evidenced by. Only that she is breastfeeding...which isn't a NDx. Also, pregnancy isn't a NDx.

Sorry I'm not much help, but I can see why you're confused. Pick 6 diagnoses w/ no assessment data? Doesn't work.