Tearing my hair out Postpartum Diagnosis

  1. Last semester in foundations I totally rocked at careplans. Even got the highest remarks available under documentation from my clinical instructor. Now I am losing my mind in OB. I have the most awesome clinical instructor, however when it comes to careplans I am running my head into a wall. I am not allowed to use pain, risk for infection, or anything else that is considered "normal" for postpartum . My patient was a repeat Csection about 30 yrs old with no complications other than she couldn't seem to pass gas for us and she couldn't speak english. So I have the communication factor in my care plan... but as I couldn't communicate with her and the hospital doesn't have an interpreter <sp> I am having a difficult time coming up with other non standard post c section diagnosis. Any thoughts?
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    About OnTheRoad

    Joined: Feb '06; Posts: 180; Likes: 23


  3. by   kimber1985
    Ineffective coping
    Disturbed Body image

    In OB I would make up my own Dx and we were suppose to, because the book (Cox) is not directed at OB. I had a pt whose significant other was in prison at the time.... That was Interrupted Family Process. It is still from the book, but not often used. Since birth is a normal life process and not a disease it is hard to come up with useful Dx, go with psychosocial. Even a C-sect is a Distrubed Birth Process. Sleep Deprivation from nursing the baby and being awake for hours of labor. Maybe you could use Exhaustion. You said she doesn't speak English....does she have Health Care??? You could use that.
  4. by   Daytonite
    First of all, let's work through the pathophysiology of what is going on with this patient. A patient who has had a C-section has had a surgery where some sort of anesthesia was used (I'm assuming an epidural). Was the decision to do the C-section made after the patient was already in labor? Or, was this a planned C-section? What are the common complications for the type of anesthesia that was used and was the patient thoroughly assessed for any of the symptoms of them? If the patient was in labor as well, then there was muscular activity involving the uterus. The pushing of the baby against the pelvic structures creates some trauma to the mother's tissues. When there is any kind of trauma, even the smallest boo-boo, the body responds by initiating protective protocols. The result is the local tissues swell as the blood supply to the area increases. Swollen tissues create some problems, particularly if they are pushing against other tissues and organs. So, you have to keep in mind the organs that are contained in the pelvic area that are subject to this (urinary bladder, part of the large intestine, genital organs). With surgical intervention these same protective responses of the body are going to be initiated because there has been a foreign invasion by the surgeon with mechanical manipulation of the tissues.

    Here is a list of the common complications of surgical patients undergoing general anesthesia:
    • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
    • hypotension (shock, hemorrhage)
    • thrombophlebitis in the lower extremity
    • elevated or depressed temperature
    • any number of problems with the incision/wound (dehiscence, evisceration, infection)
    • fluid and electrolyte imbalances
    • urinary retention
    • constipation
    • surgical pain
    • nausea/vomiting (paralytic ileus)
    Complications of epidural anesthesia are:
    • hypotension
    • rash around the epidural injection site
    • nausea and vomiting from the opiates administered
    • pruritis of the face and neck caused by some epidural narcotics
    • respiratory depression up to 24 hours after the epidural
    • cerebrospinal fluid leakage and spinal headache from accidental dural puncture
    • sensory problems in the lower extremities
    You have a incision. Impaired Skin Integrity R/T surgical intervention is an appropriate diagnosis to use. Your nursing interventions under this diagnosis would include monitoring and care of the surgical incision.

    Constipation should be considered a problem due to swelling of the internal tissues until the patient passes their first stool. If your patient is not passing gas, then it is likely that she is going to be constipated considering the amount of narcotics she got during the C-section. Likewise, until the patient is voiding adequately, urinary problems need to be watched for. If the mother was in labor before the C-section and doing some pushing, there may be hemorrhoids that need attention.

    If the mother is breastfeeding, there are several nursing diagnoses that address this for both the mother who is breastfeeding without problems and those who are having problems: Effective Breastfeeding, Ineffective Breastfeeding, and Interrupted Breastfeeding.

    Was there blood loss during surgery? What was the patient's fluid status prior to surgery? What about after surgery? Were there any food or fluid restrictions? The consideration of a nursing diagnosis of Deficient Fluid Volume is most appropriate.

    With surgical invasion there is often Acute Pain.

    After labor and delivery and/or C-Section mothers are usually pretty fatigued. There is a nursing diagnosis for this: Fatigue.

    If you really want to get fancy there are also these nursing diagnoses:
    • Knowledge Deficit (learning need) regarding physiological changes, recovery period, self care and infant care
    • Situational Low Self-esteem (R/T failure to complete normal labor and delivery)
    • Any of the Self-care deficits R/T effects of anesthesia, decreased strength and endurance and/or physical discomfort
    • Sleep Deprivation R/T hormonal or psychological responses, pain, fatigue of labor and delivery and/or demands of family
    • In older books Doenges and Moorhouse include Family Coping: potential for growth R/T sufficiently meeting individual needs and adaptive tasks, enabling goals of self-actualization to surface AEB family member(s) moving in direction of health-promoting and enriching lifestyle
    • Ineffective Role Performance R/T situational crisis (demands of new family member, changes in responsibilities of family members)
    • Disturbed Body Image [some women don't handle having surgical scars very well!]
    • Ineffective Sexuality Pattern R/T altered body structure or function
    • (Risk for)Impaired Parenting
    • Risk for Impaired Parent/Child Attachment
    • Risk for injury (any of the postoperative complications that can occur, ie. anemia, tissue trauma, rubella sensitivity, Rh incompatibility, thrombophlebitis)
    • Risk for Infection
  5. by   morte
    daytonite....the part i dont get is the op states that she isnt being allowed to use any of those "standard" post c-section dx...such as risk of infection, pain.......what could this instructor be getting at?
  6. by   Daytonite
    Quote from morte
    daytonite....the part i dont get is the op states that she isnt being allowed to use any of those "standard" post c-section dx...such as risk of infection, pain.......what could this instructor be getting at?
    well, my instructors in my bsn program were the same way. this whole nursing diagnosis business is actually a matter of language and the words you use to put these things together. so, you can do a lot of word play with these nursing diagnostic statements you write as long as you stay within the parameter of the definitions of the actual nursing diagnoses. i actually wrote my response to this thread on a word document and then copied and pasted it as a reply. after i submitted it i noticed that the op had said they couldn't use pain in their care plan. well, actually it can be used, just not as it's own nursing diagnosis. pain can be addressed and nursing interventions developed for it, but under another nursing diagnosis such as impaired skin integrity or the self-care deficits. this whole care plan writing business, particularly these nursing diagnostic statements, has evolved into word play. to me, working with nanda is kind of like playing scrabble. you have a bunch of tiles that represent consonants and vowels (related factors and defining characteristics). you have to put them together into words (nursing diagnoses) that make some kind of sense. the way you verify that you've chosen correctly is to make a nursing diagnostic statement that consists of a nursing diagnosis--related factor--defining characteristic. if you've followed the nomenclature and taxonomy rules of nanda that are based on the nursing process everything should be hunky dory. the thing is, and most people may not be aware of this, is that what nanda has published to go along with the nursing diagnoses is what has come from research sponsored by them. they are very open about saying that nurses should also feel free to customize where they feel it is necessary when dealing with the related factors and defining characteristics for each nursing diagnoses. but, when you do this, you should know what you are doing and what the definition of the nursing diagnosis is when you are tweaking the elements going with it. this is why i will occasionally mention that you should look at the definition of the nursing diagnosis to make sure it is describing the problem you are trying to say your patient has. if it doesn't, then you've probably got the wrong nursing diagnosis.

    does that help explain that? unfortunately, i didn't understand all this until i graduated from my nursing program and had been out at jobs working with it for some time. this stuff is so incredibly hard to understand that i don't know of many nursing instructors who really are able to explain it very well. i don't think it's their fault. i think this whole nursing diagnosis stuff is just plain old hard to understand until you've worked with it for awhile. and, doing 5, 10 or 20 care plans in school by no means makes anyone proficient in working with it, sad to say. i can tell from the questions asked on the forums. they are almost always about how to arrive at or choose a nursing diagnosis. always. if nanda did anything, they managed to make something that used to be quite simple incredibly hard and confusing. part of the blame for this goes to medicare.

    sorry to rag on like this.
  7. by   OnTheRoad
    I asked my instructor the last day of clinical about the care plans. It seems to me that she really doesn't like care plans in general. She really wants our OB clinical section to switch to clinical pathways. Seeing as she has to have us do careplans she wants us to think on our own and has seen too many canned careplans. I ended up doing impaired communication and activity intolerance. The problem I ran into is that most of my interventions could not be fullfilled within this particular hospital setting as there is no interpretor available... period. I am wondering if alot of hospitals have this problem when they have non english speaking patients.
  8. by   GingerSue
    just curious - has anyone ever utilized over-the-telephone interpretation services? - this is mentioned in my assessment textbook
    The example providee is AT&T operated the Language Line Services since 1989 which provides interpretation in more than 140 languages.
    The description says that services are available around the clock every day of the year - call (800) 628-8486 (I don't know what the charges are)
  9. by   Kelky
    I have used the ATT line and in person translators. I found the ATT line difficult, yes they may both speak spanish, but there can be different dialects, words used etc, and the pt is in a scary situation and may not understand the words used by the interpretor but agree anyway. I find it very nerve wracking and don't always feel comfortable that the pt really understands everything. Also it is hard to hear, the phone lines are not always great. In person translators are much better, a lot of communication is non verbal and it is easier to ensure understanding face to face. I expect they're much more expensive though.
  10. by   Lesli61
    Getting back to the original question... My instructors are saying the same thing. They will not accept any of the 'usuals' like pain, constipation, fluid volume deficit, etc. The reasoning is that they want us to focus on the FAMILY not just the physical condition of the patient. Look for bonding with infant, family processes, knowledge deficits, or 'Ready for enhanced knowledge...' (my personal favorite because any mom, even experienced, can learn something new. Hope that helps.
  11. by   AJPV
    Funny thing, I thought nursing school was supposed to teach us how to care for the most RELEVANT patient needs! Instead, we're putting all our energy into creating "original" and "unique" care plans that stray increasingly far from the patient's most pressing MEDICAL needs! I wonder how well it well go over when a new grad nurse is being sued for not recognizing signs of postpartum hemorrhage or infection because the nurse was too busy trying to play social worker. It feels like we're in a scrabble tournament instead of learning real medical knowledge & skills.