I am working on my first care map for my maternity clinical. I want to be sure that I am not reaching when it comes to my nursing diagnosis for my newborn. The newborn I had was born by cesarean. The baby's O2 SATs were 55% at birth and after suctioning was up to 84%. She was in the special care nursery for about 9 hours to which at that point her oxygen was around 98% on room air.One of the diagnosis I have come up with for her is:Impaired gas exchange r/t an inability to move secretions independently AEB an oxygen saturation of 55% at birth and the need to use suction to clear airway at birth (3ml of fluid removed).Since she is now stable enough to be back with mom is this diagnosis no longer relevant?
Editorial Team / Admin Rose_Queen, BSN, MSN, RN 6 Articles; 11,338 Posts Specializes in OR, Nursing Professional Development. Has 18 years experience. Jan 31, 2015 Your nursing diagnoses should be based on your assessment of the patient. If your assessment is showing that the baby is no longer having issues with oxygenation (O2 sat of 98%), then yes, this diagnosis is no longer relevant.
Esme12, ASN, BSN, RN 4 Articles; 20,908 Posts Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 43 years experience. Jan 31, 2015 Think about the risks to the newborn....any newborn....why are we concerned about the baby being kept warm? What do we instruct mother to look for on the umbilical cord stump? The heel sticks might be a source to become infected but wouldn't the stump be more important? Why would the mother have ineffective bonding? What about your assessment supports this diagnosis? Is this her first baby? Is she breast feeding? Was the baby full term? TELL ME ABOUT YOUR PATIENT. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive that diagnosis. Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse. Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.https://allnurses.com/nursing-student-assistance/nursing-care-plans-681800.html
SueSNACC 3 Posts Feb 2, 2015 Thank you! I don't like just having risk diagnosis, but I guess in the case of a healthy newborn that is all we have.
nurseprnRN, BSN, RN 2 Articles; 5,114 Posts Feb 2, 2015 Thank you! I don't like just having risk diagnosis, but I guess in the case of a healthy newborn that is all we have.I hate this. I hate it that faculty are somehow giving students the idea that "risk for" diagnoses are somehow inferior or not important. If that were your baby girl lying in the bassinet next to your bed, would you think that a nurse who considers that she could be at risk for body temp imbalance/hypothermia, infection, aspiration, or injury was being substandard or lazy or somehow giving your infant short shrift because those weren't "actual" diagnoses? Because "that is all we have"? If you don't have the NNDA-I 2015-2017, you are missing the big picture (and not just with healthy newborns). There's an entire section on safety in there, and most of the diagnoses in it begin with "risk for..." If you don't think safety and protection from possible injury are among the biggest duties a nurse owes a patient, then ... then ... aw, hell, I'm speechless.
RunBabyRN 3,677 Posts Specializes in L&D, infusion, urology. Has 2 years experience. Feb 4, 2015 Have you researched O2 saturations on newborns? How long after birth were these the O2 saturations? Were they preductal or postductal? For the first 10 minutes post-birth, O2 sat is below that of other patients. Anything else the baby might be at risk for if we are trying to jack his or her O2 to 100% immediately after birth?Were you with this infant when she was born and going through all of this? You need to consider diagnoses that are relevant while you are with the patient. Remember that nursing diagnoses aren't always about what's going WRONG. How is she feeding? How is she bonding? How is she maintaining her temp? What else could be going on with an infant? Look beyond MEDICAL diagnoses.
