Skip to content
View in the app

A better way to browse. Learn more.
allnurses

A full-screen app on your home screen with push notifications, badges and more.

To install this app on iOS and iPadOS
  1. Tap the Share icon in Safari
  2. Scroll the menu and tap Add to Home Screen.
  3. Tap Add in the top-right corner.
To install this app on Android
  1. Tap the 3-dot menu (⋮) in the top-right corner of the browser.
  2. Tap Add to Home screen or Install app.
  3. Confirm by tapping Install.
Discussion

Nursing Care Plan

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!

  • Quote

    • Featured Replies

    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:

  • Quote

    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!

  • Quote
    • Author

    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?:)

  • Quote

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

  • Quote

    • Join the conversation

    You can post now and register later. If you have an account, sign in now to post with your account.

    Guest
    Add a Comment
    Go to topic listing

    Currently Reading 0

    • No registered users viewing this page.

    Account

    Navigation

    Search

    Search

    Configure browser push notifications
    Chrome (Android)
    1. Tap the lock icon next to the address bar.
    2. Tap Permissions → Notifications.
    3. Adjust your preference.
    Chrome (Desktop)
    1. Click the padlock icon in the address bar.
    2. Select Site settings.
    3. Find Notifications and adjust your preference.