1. Risk for disturbed body image related to post-partum abdominal size manifested by patient stating "I still feel fat even after the baby came out".
2. Imbalanced Nutrition that is more than body requirements related to excessive weight gain manifested by weight gain of more than 45 lbs during pregnancy.
3. Risk for Impaired Parenting related to young age as manifested by patient being only 19 years of age.
4. Risk for Impaired Gas exchange related to patient stating she smokes as manifested by SpO2 level of 94%
5. Constipation related to pregnancy as manifested by patient not having a BM within first day of post-partum
6. Acute Pain related to right labial laceration manifested by patient asking for Motrin for pain.
7. Role strain related to insufficient finances as indicated by patient being on Medicaid.
As it is, we have to find the three priority nursing diagnoses for our care plan. I was thinking the first one be acute pain, followed by risk for impaired gas exchange, followed by Imbalanced Nutrition. Thoughts?
Also what is a nursing diagnoses for addiction related to her smoking? I would not find that to be a priority one, but I still think I want to list it with the rest of my normal diagnoses.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thats my understanding with pain. Its a physiological sign so according to Mazlows hierarchy of needs it is certainly a priority diagnosis. I obviously did not include assessment data in my question but it is present in my careplan (did you guys assume I forgot to assess?). My patient had no real life threatening problems so acute pain related to a labial laceration could be one.
No I didn't assume you didn't assess her but how can I help with priority if I don't know her assessment? Are you sure it was a labial laceration and not from an episiotomy or lady partsl tear? The peritoneal pain is not just from lacerations it is from the brutal forces during childbirth? What did the chart say? Wouldn't she also be at risk for infection? Did she have sutures in her perineum? If she has a laceration wouldn't that be a nursing diagnosis as well?
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I'm using Davis's Nurses Pocket Guide by Doenges, Moorhouse and Murr. We were told that we must have a "manifested by" for all nursing diagnoses. I'm assuming that is for risk as well, I dare not go against what our instructor said, since its pass or fail.
Never assume. Once a patient has signs of an infection the at risk diagnosis no longer applies.
According to NANDA....For risk diagnoses, there are no related factors (etiological factors), since we are identifying a vulnerability in a patient for a potential problem; the problem is not yet present. Therefore we identify the risk factors that predispose the individual to a potential problem.
The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced by __________________________ (Risk Factors).
Risk Diagnosis Example: Risk for infection as evidenced by inadequate vaccination and immunosuppression (risk factors)."
Esme12, ASN, BSN, RN
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