Pt 24yo female 1 day postpartum. Baby is in NICU due to other complications but only the mother was my pt. I need five diagnoses total and I only have four. If there is any input on the four I have already that would be appreciated also. Due in 24hrs.
A. Ineffective breastfeeding
r/t situational crisis AEB pt verbalization of not being able to breastfeed while her baby is in the NICU.
NOC: Pt will use breast pump effectively by the end of shift.
1) Educate pt on the use of the pump. This will ensure correct use.
2) Assist pt with use until the pt feels confident to use independently. Assisting the pt will ensure confidence when performing independently.
3) Observe pt use breast pump independently. Observing will confirm correct use.
Eval: Goal met; Pt demonstrated correct use of the breast pump independently as 1130. Cont. POC
B. Acute pain
r/t episiotomy AEB pt states, "It hurts when I sit or walk. I would rate my pain at a 6 or 7. I really need something to make the pain better."
NOC: Within 4 hours of interventions pt will experience a decrease in pain level by reporting a pain score of 2 or less.
1) Administer analgesic medication as ordered as needed to promote comfort.
2) Explain discomforts and reassure the pt that they are time limited to assist in coping with pain,
3) Administer stool softener to prevent straining with first bowel movement
Eval: Goal met; Pt stated pain level at a 2 one hour after interventions. Cont POC
C. Impaired tissue integrity
r/t episiotomy AEB 3rd
degree laceration in the perineal area
NOC: The pt will remain free of infection through out shift, without any signs and symptoms of infections, and exhibit evidence of progressive healing as demonstrated by clean, dry, absent edema, and intact episiotomy site.
1) Monitor episiotomy sire for redness, edema, warmth or discharge to identify infection
2) Instruct pt on use of sitz bath to promote healing, hygiene and comfort.
3) Encourage frequent perineal care and peripad changes to prevent infection
4) Instruct pt on positioning to relieve pressure on perineal area
Eval: Goal met; Pt showed signs of progressive healing as demonstrated by clean, dry, absent edema and intact episiotomy site.
D. Risk for ineffective coping
r/t mood alteration and pain
NOC: The pt will cope with mood lacerations, by verbalization of positive statements about newborn and participation in new born care
1) Provide a supportive, nurturing environment and encourage the mother to vent her feelings and frustrations to relieve anxiety
2) Encourage pt to travel up to the NICU to spend time with the newborn
3) Offer praise and reinforcement of positive mother-infant interactions to enhance self-confidence in care
Eval: Goal met; "Even though it hurts to walk I feel that it is worth it to go and see the baby."