Help with a third nursing diagnosis.

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I have a patient who delivered this morning. 2nd degree perineal laceration with her lady partsl delivery. She had an epidural but only voided twice since it was discontinued with 50-100ml amounts. My first nursing diagnosis was Acute pain r/T 2nd degree perineal laceration AEB pt states "my pain is 5/10 from the delivery and I'm swollen like a peach." My second diagnosis is risk for infection r/T second degree perineal laceration from lady partsl delivery. My third diagnosis I wanted to use something related to a risk for urinary retention? I'm not sure if I'm heading in the right direction here, so any advice is welcome. She did state she has no urge to void and has only voided when being toileted and didn't realize she was voiding.

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Specializes in Nephrology, Cardiology, ER, ICU.

Moved to nursing student assistance forum

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Urinary retention sounds good, it can even feed into the risk for infection.

Think for a moment though, what risk does a post partum mother have if their bladder gets distended?

Mind you, not a maternity nurse. Just finished my maternity clinical and had the risks for complications in my head the last several weeks.

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If it's full, it can prevent the uterus from involution and lead to postpartum hemorrhage. Her fundus was firm and at the level of the umbillicus. It can also cause damage to the urinary bladder muscles, kidney infections & UTIs because her muscles are already weakened from delivery.

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You got it. :)

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krissyycupcake said:
If it's full, it can prevent the uterus from involution and lead to postpartum hemorrhage. Her fundus was firm and at the level of the umbillicus. It can also cause damage to the urinary bladder muscles, kidney infections & UTIs because her muscles are already weakened from delivery.

You can look at this as risk for injury, impaired urinary elimination, urinary retention; look those up in your NANDA-I 2015-2017 and see which defining characteristics fit your patient assessment.

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Specializes in Public Health, Maternal Child Health.

Any woman that just delivered a baby... ALWAYS think risk for PP hemmorage. It happens left and right all the time. Out of nowhere. Always an appropriate dxn

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Specializes in NICU, RNC.

Your #1 nursing dx should be risk of bleeding. This is the most life-threatening complication and is an issue for every single post pardum patient. Making sure she empties her bladder regularly would be an intervention to prevent this complication. #2 is risk of infection. #3 is pain. Always always always focus on what would kill the patient first. Pain doesn't kill people. It's still important, but it's #3.

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Specializes in Pediatrics and Nursing Education!.

Good feedback here!

I'd just add to keep in mind actual vs. potential... Actual diagnoses should be the priority over potentials.

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tootRN said:
Good feedback here!

I'd just add to keep in mind actual vs. potential... Actual diagnoses should be the priority over potentials.

Common misconception, although it sounds good if you don't have any experience or you swallow everything that's fed you.

If you don't think risk for infection isn't a BIG priority in any patient with immune suppression, for any reason, you are soooo missing the boat.

If you don't think risk for injury isn't a huge priority in an osteoporotic old lady who gets out of bed all the time, you'll be on my desktop from your lawyer when she falls because you didn't think it was important to put a bed alarm in her chair AND HER BED.

If you don't think risk for aspiration is pretty close to the tippy-top of things a plan of nursing care ought to address, I don't want you taking care of my mother post-CVA.

If you're working in OR and you don't think risk for perioperative positioning injury isn't the first thing you think of when you help the patient off of the stretcher, I'll see you in court, too.

If you have a patient with a burn injury and don't think risk for imbalanced body temp is worth a hill of beans, you don't know that skin maintains body temp and these people need you, the nurse, to recognize their inability to do what you and I take for granted, maintain our healthy body temp, and keep them warm and tanked up with calories.

If you think risk for disturbed maternal-fetal dyad isn't really important, let me show you some abused and neglected infants on their third readmit.

Wanta rethink that?

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