HELP!! Nursing diagnosis for PostPartum mom

Nursing Students Student Assist

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So, Im having a hard time coming up with nursing diagnosis for a mother who is Postpartum day 1. She is a multigravida, G3 P2.

What I found when doing the assessment was: an elevated fundus two finger breaths above umbilicus. Im trying to come up with a nursing diagnosis for this since this is the only problem she is having.

She had a lady partsl deliver with no complications at all.

PLEASE HELP!!!

Nursing diagnosis for a normal pp vag delivery would include-

*risk for pain (even if she isn't having any),

*knowledge defecit (education is HUGE in postpartum)- SIDS, shaken baby, breastfeeding, when to call doctor for MOM, when to call doctor for BABY, activity restrictions, diet, post partum depression, etc.

*risk for bleeding - any pp mom has a risk for bleeding. The high fundus may or may not indicate her risk is elevated. Is her uterus firm and midline? Where was her uterus right after delivery? 4 hours ago? How is her bleeding? How is her urine ouput?

*risk for falls (cause everyone is)

Specializes in L&D, infusion, urology.

Readiness for enhanced family process, effective breastfeeding... There are a ton in postpartum. Do you have to focus on something "wrong", or can you look at what's going WELL? I precepted in postpartum, and had to do nursing diagnoses in my log.

WHY was her fundus high? Was she boggy? Urinating Q2H? Was there any pain/discomfort/cramping associated with this? Elevated temp? High WBCs?

Did she have a lady partsl birth? Any tearing/episiotomy? Any pain? Risk for infection?

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Does she have an episotomy? Was this full term? How is the baby? Is she breastfeeding? Why or why not? Does she have a supportive partner? Is this her first baby? Did she have an epidural? How long did she labor?

How is her interaction with baby? How is her interaction with family?

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