Nursing Care Plan

Published

I am doing a care plan for my patient with a 1st degree laceration post vag. delivery. I have NOTHING to report in the subjective data section. My nursing diagnosis is Risk for infection d/t laceration r/t lady partsl delivery. Patient reports no pain, there is no redness, edema, ecchymosis, discharge, etc. I am stuck!

Up Vote Up Vote ×
Specializes in CVSICU, Cardiac Cath Lab.

Well, if she doesn't have any c/o, then perhaps using a different diagnosis would work. I haven't had L&D yet, but would knowledge deficit work (is she a 1st timer?). How is she coping?

Good luck! Care plans are so much fun :uhoh3:

Up Vote Up Vote ×
Specializes in LTC, Correctional Nursing.

Is she breastfeeding? Is she diabetic? Was she induced? How is she coping? Is this her first? Any volume depletions? I have taken OB and I can help you... I just need more info.

Here's some ideas...

Decisional conflict r/t perceived threat to idealized birth

Risk for imbalanced fluid volume r/t IV therapy

Self esteem disturbance r/t inability to carry out normal labor

acute pain r/t cracked nipples

impaired skin integrity r/t mechanical factors involved in suckling, breastfeeding management

The list goes on....

I recommend that you get a Nursing Dx book... I have one and it's invaluable!

IBSN# 0323036643

Good luck!

Up Vote Up Vote ×

Thanks for your replies. I actually filled out the entire care plan and used "pertinent negatives," (i.e., patient denies, pain, burning upon urination, etc) for the subj. data portion. I guess you can actually have negative subjective data, but still have risk factors for nursing diagnoses. Who knew?:)

Up Vote Up Vote ×
Specializes in LTC, Correctional Nursing.

Sure you can! Not everything will be positive. :) Glad you got it done!

Up Vote Up Vote ×
+ Join the Discussion