New to the site and needing help with Postpartum Nursing Diagnoses and Interventions

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Hello! I am needing help with some nursing diagnoses for a postpartum patient. I am new to this site so I hope I am posting in the correct place. Forgive me if I am not. This is my first year in nursing school and my first semester in the clinic and they gave us OB. My pt. had a lady partsl delivery with a 2nd degree episiotomy. She said she was sore at the episiotomy site and that it hurt to get up and down off of the bed. She is breastfeeding and even though I never saw her do it she said the baby was taking to breast well. She did gain 57 pounds during pregnancy although with her BMI she should have gained 15-25 pounds. This is her first child and she has a great support system in place. I am needing two diagnoses and one psychosocial diagnosis and three to 4 interventions each. My instructor wants the interventions to be specific and she wants all of the diagnoses in order. If anyone can help me I would appreciate it. Here is what I have so far:

1. Acute pain R/T trauma to perineum during labor and delivery AEB pt. stating she was "sore and it was hard to get up and sit down".

1. Assess and document pain level q 2 hrs

2. Give pt. ice pack to put on her perineum; 20 mins on and then off for 1 hr.

2. Risk for infection R/T skin trauma secondary to 2nd degree episiotomy

  1. Assess REEDA q shift
  2. Assess WBC count in urinalysis/urine stick for infection.
  3. Instruct pt. to wipe from front to back
  4. Change perineal pads after each voiding.
  5. Encourage pt. to clean perineal area after voiding or defacating with either a sitz bath or a peri bottle.

3. Imbalanced nutrition: more than body requirements R/T gaining more than 15-25 lbs during pregnancy.

Not for sure about interventions because since she is breastfeeding she needs more calories. What would I assess for?

Also, I want to do something with breastfeeding but I don't know what. She is breastfeeding fine with no problems.

4. Readiness for enhanced breastfeeding

What should my interventions be?

Once again I appreciate any help I can get. Thanks!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
hello! i am needing help with some nursing diagnoses for a postpartum patient. i am new to this site so i hope i am posting in the correct place. forgive me if i am not. this is my first year in nursing school and my first semester in the clinic and they gave us ob. my pt. had a lady partsl delivery with a 2nd degree episiotomy. she said she was sore at the episiotomy site and that it hurt to get up and down off of the bed. she is breastfeeding and even though i never saw her do it she said the baby was taking to breast well. she did gain 57 pounds during pregnancy although with her bmi she should have gained 15-25 pounds. this is her first child and she has a great support system in place. i am needing two diagnoses and one psychosocial diagnosis and three to 4 interventions each. my instructor wants the interventions to be specific and she wants all of the diagnoses in order. if anyone can help me i would appreciate it. here is what i have so far:

1. acute pain r/t trauma to perineum during labor and delivery aeb pt. stating she was "sore and it was hard to get up and sit down".

1. assess and document pain level q 2 hrs

2. give pt. ice pack to put on her perineum; 20 mins on and then off for 1 hr.

2. risk for infection r/t skin trauma secondary to 2nd degree episiotomy

  1. assess reeda q shift
  2. assess wbc count in urinalysis/urine stick for infection.
  3. instruct pt. to wipe from front to back
  4. change perineal pads after each voiding.
  5. encourage pt. to clean perineal area after voiding or defacating with either a sitz bath or a peri bottle.

3. imbalanced nutrition: more than body requirements r/t gaining more than 15-25 lbs during pregnancy.

not for sure about interventions because since she is breastfeeding she needs more calories. what would i assess for?

also, i want to do something with breastfeeding but i don't know what. she is breastfeeding fine with no problems.

4. readiness for enhanced breastfeeding

what should my interventions be?

once again i appreciate any help i can get. thanks!

diagnosis of knowledge deficit: breastfeeding and the process of lactation rt client being a first time mother aeb client stating she does not know the process of lactation or how to breastfeed...

1. teach breastfeeding preparation

a. infant's readiness to feed: awake, sucking on hands, smacking lips, and slight fussiness

b. teach mother to apply heat to entire breast or to take a hot shower prior to feeding.

c. provide pillows or blankets to use as support.

2. teach mother breastfeeding techniques

a. demonstrate to mother how to hold infant

b. teach mother correct latch on techniques.

3. teach mother helpful tips for after breastfeeding

a. teach the mother to start breastfeeding 10-15 minutes on each breast 8-12 times a day.

b. teach mother to place cold packs on immediately following feedings.

any nursing diagnosis that you choose should be based upon the symptoms your patient is having. you should also be using some sort of nursing diagnosis reference the has the nanda taxonomy so you are classifying the diagnosis correctly.

since risk for ineffective breastfeeding is not a nanda approved diagnosis you will have to be careful how you are going to use this. the definition of ineffective breastfeeding is dissatisfaction or difficulty a mother, infant or child experiences with the breastfeeding process [page 24, nanda-i nursing diagnoses: definitions & classification 2007-2008]. so, i don't have to type out the symptoms (defining characteristics) of this diagnosis, you can read the list of them on this webpage: [color=#3366ff]ineffective breastfeeding. so, in essence, to use risk for ineffective breastfeeding you are anticipating or trying to prevent any of those symptoms listed under ineffective breastfeeding from occurring. your nursing interventions will be to monitor for some of those specific symptoms (you know this patient best and what you expect she might do) and/or head them off at the pass. your outcomes/goals will be the anticipated results of your nursing interventions for this diagnosis.

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