Is this a good OB c-section diagnosis?

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I had a patient with a history of genital warts/hpv, a current UTI, that had birth via primary c-section. I was thinking an appropriate diagnosis would be "risk for infection related to rupture of amniotic membranes and present infection" but i am completely stumped as to whether this is appropriate or not, since her vitals looked find intra and post operative; however, I was thinking she could be at potential risk due to her current UTI. What do you guys think?

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.
I was thinking an appropriate diagnosis would be "risk for infection related to rupture of amniotic membranes and present infection"

Re: the bolded - can you think of why this might not be an appropriate dx for a postpartum patient?

With someone who had a c/section, can you think of other reasons why she might be at risk for infection?

When was her UTI diagnosed?

Well for someone who had a c-section, I would think other reasons for infection can be from the major abdominal surgery itself. As for time of diagnosis, i believe a week before labor.

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

Did she start taking abx a week before labor or was she still untreated at delivery? If it's the former, do you know what a typical antibiotic regimen is for UTI in pregnancy?

With that in mind, do you think the antenatal UTI has any relevance to her postpartum course of care? In other word, is this really a CURRENT UTI?

Specializes in General Surgery.

I would be thinking along the lines of postoperative care.

Have you done medical-surgical yet? If so then you realize that most Nursing Dx for postoperative patients automatically fit her, yes?

I don't recall the official nursing diagnosis names but the following things come to mind.

VTE prophylaxis

-SCDs

-TED Hose

-Ambulation

-Pain control to allow these interventions

Prevention of atelectasis

-Insensitive Spirometry

-Cough Deep Breathing

-Ambulation

-Pain control to allow these interventions.

Pain

-Pharmacological means

-Nonpharma means

Discharge Planning

-Is she ready to care for baby?

-Assess her readiness

-Provide education such as feeding, sleeping, umbilical cord care, and immunizations.

-Recognizing symptoms of SSI.

I had a patient with a history of genital warts/hpv, a current UTI, that had birth via primary c-section. I was thinking an appropriate diagnosis would be "risk for infection related to rupture of amniotic membranes and present infection" but i am completely stumped as to whether this is appropriate or not, since her vitals looked find intra and post operative; however, I was thinking she could be at potential risk due to her current UTI. What do you guys think?

Briefly, I think you're right, due to the membrane rupture. Sometimes it really is that simple.

You can't say, "Risk for" if she already has one related to that, though; it's no longer a risk, it's an active problem.

However, she can have both an active infection due to her membrane rupture AND be at risk for infection from other causes. As noted in previous posts, she may well also have other risk factors for infection, and it is perfectly possible (and actually desirable) to list more than one if they exist in this patient. See the whole picture, not just the one thing.

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