My patient was a 20 y.o pregnant female G1 P0. She was admitted to the hospital for a 23 hour observation. She had had a dizzy spell at home, fell and hit her stomach on the tub. When she was admitted to the hospital she had light vaginal bleeding and contractions q2-5 mins with no cervical change. By morning the bleeding had stop and her contractions had become irregular. When I was assigned this patient, she was sent home a few hours later so I wasn't able to do much with her. I'm not exactly sure what my nursing dx would be for her. Any information would be greatly appreciated. THanks in advance.
Apr 7, '08
How was her demeanor, I'll be t she was anxious or fearful needed further teaching on activities and checkups etc... (think of some psych social dx taht would fit)
What caused the dizzy spell? Is there an underlying issue or normal changes r/t pregnancy? either way she is probably at risk for having another one (risk for injury related to....)
just a few ideas to get you starrted.
Apr 7, '08
Nursing diagnoses are ALWAYS based on evidence in the form of abnormal assessment data that you collected.
- had a dizzy spell at home, fell and hit her stomach on the tub - if this had been more thoroughly investigated by the docs and the reason for the dizziness (syncope) known (cardiac, cerebral) a physiological diagnosis could be used, but without that info. . .
- Risk for Maternal Injury R/T dizziness or Risk for Falls R/T no antislip material in bathtub
- Risk for Fetal Injury R/T delivery of preterm infant
- light vaginal bleeding, by morning the bleeding had stopped
- Fluid Volume Deficit
- Risk for Fluid Volume Deficit
- contractions q2-5 mins with no cervical change, by morning her contractions had become irregular
- Activity Intolerance R/T injury to uterine tissues AEB irregular uterine contractions (basically, this diagnosis will support the discharge instructions that advised the patient to stay in bed and rest in order not to aggravate the contractions she was having)
- Anxiety R/T threat to fetus
- Fear R/T threat of death of fetus
- Knowledge Deficit, treatment needs/prognosis