Are nursing diagnoses only from actual assessments or can it come from labs too?

[lovecorinth]

I assessed a mother in the postpartum floor. She has no prior medical history, no complications during labor, newborn was normal with no complications. She was in her PPD #1. She had normal vital signs and pain was a 0. She walks around often, eats regular food, voids, and has maximum interaction with her baby. She breastfeeds her son. I did assessments and didn't find any abnormality. She hasn't had a bowel movement yet and she knows to drink a lot of water, ambulate, and eat foods with fiber.

I looked into the possible nursing diagnoses and fatigue wouldn't fit her because she said she does feel tired. Pain, I can't do because she reports of no pain. She breastfeeds which was effective.

The only abnormality was her Hgb and Hct values which were low. Can I use THESE into nursing diagnoses even though I'm not using the actual assessments I did? I planned on doing risk for injury due to abnormal lab values.

[wish_me_luck, BSN, RN]

I assessed a mother in the postpartum floor. She has no prior medical history, no complications during labor, newborn was normal with no complications. She was in her PPD #1. She had normal vital signs and pain was a 0. She walks around often, eats regular food, voids, and has maximum interaction with her baby. She breastfeeds her son. I did assessments and didn't find any abnormality. She hasn't had a bowel movement yet and she knows to drink a lot of water, ambulate, and eat foods with fiber.

I looked into the possible nursing diagnoses and fatigue wouldn't fit her because she said she does feel tired. Pain, I can't do because she reports of no pain. She breastfeeds which was effective.

The only abnormality was her Hgb and Hct values which were low. Can I use THESE into nursing diagnoses even though I'm not using the actual assessments I did? I planned on doing risk for injury due to abnormal lab values.

Labs too. For example risk for bleeding r/t ... as evidenced by low platelet count, etc. (this is an example); then you have to consider people who are post op, if they have low albumin or something, they are less likely to heal easily which puts them at risk for infection and complications

[KelRN215, BSN, RN]

You can use abnormal lab values in making a nursing diagnosis but don't forget that you always have all the teaching-focused nursing diagnoses. Teaching is a big part of the nurse's role, especially in post-partum.

[mindlor]

.....labs are to help you focus your assessment. I would never ever go solely on labs without looking at the patient.....just the same as I would not jump on someones chest whose tele monitor showed up in asystole without checking the patient first......

How low were the hemoglobin and hematocrit? What does that mean? Low hemoglobin? Was she having any oxygenation issues? Does she normally run low? What is her baseline? Was she showing any signs of dehydration? Many times pregnant women are low in Iron....did they run a serum iron level? Was she on iron supplement?

[jessi1106, BSN, RN]

Aside from looking at abnormal labs: Risk for Infection, and Knowledge Deficit almost always apply