Nursing Diagnosis for OB patient

[cnbowling]

I have an OB patient this is her third child and she has absolutely no emotional/medical issues. No history of medical issues nothing. I have to come up with a primary nursing diagnosis but it cannot be a risk for. Has to be about mom not baby. Was going for Effective breastfeeding but not sure what a long term and short term goal would be appropriate. Please help!

[Daytonite, BSN, RN]

This woman's body just went through a lot of trauma. Your job is to identify it and diagnose the nursing problems. I understand that you want to think that the process of childbirth is "normal", but what has happened to this female's body as a result of that "normal" process is a whole bunch of abnormal stuff compared to someone who hasn't had a baby. A care plan is based upon the assessment you made of the patient. Nursing diagnoses are determined by the abnormal data that you find. For example, after lady partsl delivery a woman's perineum is often swollen and sometimes bruised. There may have been an episiotomy or a tear that was repaired. The normal female perineum doesn't have any of that going on. There is a nursing diagnosis for this altered tissue. Re-read your OB textbook and what to assess in the postpartum mother. I think you have missed a few things.

[cnbowling]

I know that the perineal area is a good area to focus on with most patients however, this mom had little swelling, no bruising, didn't have any pain or want pain meds, no ice packs, no nothing. All I did to her this day was her postpartal assessment and get her things like ice water to drink and other non medical related things. I feel like I got the easiest patient in the world because she didn't want me to do anything. My care plan has to include three different assessments and interventions. She was great emotionally, VS were good, almost no lochia rubra present, fundus was good, breasts were good and baby was latching great. Great patient to have if you were the actual nurse in charge but not as a student looking for something to do. Am I missing something? I did a lot of teaching about what is going to happen to her body in the coming days.

[Daytonite, BSN, RN]

A little swelling is still swelling. That is Impaired Tissue Integrity. If she is breast feeding and there are no problems then that is Effective Breastfeeding. And even though everything went well, how long was labor? There is either Deficient Fluid Volume or a Risk for Deficient Fluid Volume. Read your textbook.