We are starting OB next week and have an assignment due the first day of theory to create a care plan for two patients. We were given very little information to go on and I am quite honestly a little lost. I have no problems coming up with goals, intervention, and evaluations once I have a Nursing diagnosis, but I am unsure what to put the diagnosis as since I do not have an actual patient to assess. One diagnosis needs to be "knowledge defecit" and they need to be "the most improtant ones"??? Does anyone know any resources I could use to come up with ideas for what diagnosis you would have for a patient 1 day post partum and one in latent phase?
Apr 16, '12
think about what a new mom would need to know if it is her first baby, first delivery, first breast feeding, first diaper and first pregnancy. there's a lot of teaching there.
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this should help. . .i do not have a head-to-toe assessment, but i do have an assessment data base from maternal/newborn plans of care: guidelines for individual care
, 3rd edition, by marilynn e. doenges and mary frances moorhouse based roughly on gordon's functional health needs of the normal and abnormal data that you are likely to find for a c-section patient following a c-section. you can pull the information apart and re-classify by head-to-toe. it is on page 331 of the book:
blood loss during the procedure approximately 600-800 mlego integrity
may display emotional lability, from excitation, to apprehension, anger, or withdrawal.elimination
client/couple may have questions or misgivings about role in birth experience.
may express inability to deal with current situation.
indwelling urinary catheter may be in place; urine clear amber.food/fluid
bowel sounds absent, faint or distinct.
abdomen soft with no distension initially.neurosensory
mouth may be dry.
impaired movement and sensation below level of spinal epidural anesthesia.pain/discomfort
Apr 16, '12
please do not fall into the trap of "diagnosis first, assessment second." it's the other way around. you cannot have a nursing diagnosis on a patient for whom you have no data. i am very sorry they gave you this assignment in this way.
i know, i know: you have gotten a school assignment to write a care plan on a person whom you have not met, about whom you know nothing, and whose physical and other characteristics are unknown to you. this is unfair. since they're starting you off on completely the wrong foot, through no fault of yours, you will be confused about nursing diagnosis and how it works, and how it empowers us in ways you cannot begin to imagine. i am very sorry they're doing that to you, but hang around here and esme, ashley, and i can help you.
so. in this case-- and only in this case, of a hypothetical patient-- you look at this hypothetical patient with data you get from your ob textbook.
what usually happens when pregnancy ends in birth?
what is the usual care for a postpartum patient? why?
what does a new postpartum patient need to know? to tell her nurse about if there's a problem? what kind of problem?
what about the baby? breastfeeding or bottle?
baby care? how does the new mother seem to be around her baby-- assured and confident, or scared to death and can barely touch it?
what are the most serious complications that could arise for either mother or baby? those will be your most important knowledge deficits, since symptoms will probably be reported by the mother and she will need to know what to report.