Nursing diagnosis Help

[JennSPN106]

I need some help with a nursing diagnosis.

A 27y.o. mother of 1, gave birth to two twin girls 10 hours ago. She was initially distraught r/t only planning to have 2 children, however by the 7th month she became accustomed to the idea and was looking forward to her anticipated twins.

The client was in labor for 6hrs. lady partsl birth of first infant, and cesarean was performed to deliver the second infant d/t premature placental detachment. First infant weighed 5lbs 1oz, and apgar score of 9. The second infant weighed 4lbs 4oz apgar score of 7. Both infants were placed in warmers and monitored until they were stable. Neither infants are exhibiting signs of resp. distress. even though they were small for gestational age of 38wks.

The client is now recovering, her vital signs are stable, and her dressing is dry and intact. She is fatigued and sleepy but eager to hold and care for her infants

Any help would be greatly appreciated

Thank you

Jenn

[RN BSN 2009]

How old is the first child?

She may need some refresher teaching on basic care upon discharge.

Will she be breastfeeding the twins?

Also, since this is her first cesarean, you'll want to do some basic post-op teaching (ambulate to avoid DVT, incision care.. etc..)

Good luck

[JennSPN106]

Thanks for the reply I was thinking a diagnosis would be coping, readiness for enhanced family, but I just can seem to put it together.

[Daytonite, BSN, RN]

for the mother. . .the patient had a cesarean section. this is surgery, usually with epidural anesthesia. have you done a care plan for a surgical patient before? she will pretty much have the same problems as someone who had their abdomen cut into in addition to having sustained the problems of 6 hours of labor and a lady partsl birth. what kind of beating and trauma happens to the tissues as a result of labor and one baby coming down the birth canal? what normal body response occurs when there is any trauma to the body? inflammation. its 4 cardinal signs are redness, heat, swelling and pain. they also occur when the body has been cut into by the surgeon. you can't always see the redness and swelling when it involves internal tissues like you can when it involves a scratch on the skin but i guarantee that it is there. these are symptoms that can be used as evidence for nursing diagnoses.

the potential 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

and at the very least you need to find somewhere on this care plan to have interventions where you are monitoring for them.

can she void? is she able to move around? is she having any pain? is she eating solid food yet or has peristalsis not returned yet? is she breastfeeding? these are all things that should have been assessed, and if abnormal, are problems that have nursing diagnoses associated with them. there are 3 diagnoses for breastfeeding: effective, ineffective and interrupted. what about teaching needs before discharge? what kind of questions might the mother of twins have?

for the baby. . .think about what you know about the assessment findings of a normal newborn compared to an adult. what's different? for one thing newborns can't regulate their body temperature which is why we don't leave them exposed to the room atmosphere for very long with just a diaper covering them. that's ineffective thermoregulation r/t immature compensation for changes in environmental temperature. [see https://allnurses.com/forums/f50/newborn-nursing-diagnosis-346647.html for information on thermoregulation of temperature in newborns and nursing interventions.] some newborns just have a few difficulties with excessive secretions in the respiratory track (the big hint here is that the nurses will keep a bulb syringe nearby the baby) so ineffective airway clearance can be used. they also have a stump from the umbilical cord hanging off their future belly button. do you? are they treating this cord stump? if it's inflamed or there are umbilical cord problems there is risk for infection, so you can use risk for infection r/t break in skin integrity at umbilical cord site ([color=#3366ff]risk for infection). if the baby has been circumcised that is another reason for a risk of infection. is this baby breastfeeding? if so, use effective breastfeeding. and, some babies just don't start feeding well at first by breast or bottle--it happens. these kids are imbalanced nutrition: less than body requirements r/t poor infant feeding behaviors ([color=#3366ff]imbalanced nutrition: less than body requirements).

if the baby is under the bililight for hyperbilirubinemia the nursing diagnosis to use is risk for injury r/t phototherapy ([color=#3366ff]risk for injury).