Nursing Diagnosis Help! Anemia

  1. My patient just give birth and her hemoglobin is 9.9. How would I write a nursing diagnosis for anemia? Thank you.
  2. Visit Ruba profile page

    About Ruba

    Joined: Nov '13; Posts: 22; Likes: 3


  3. by   NurseRose84
    What are her ABG's and other labs? Is she short of air? Her low Hb could put her at risk for impaired gas exchange as there aren't enough hemoglobin molecules for oxygen to bind to. There are tons of other nursing diagnoses with decreased hemoglobin as a symptom...should be able to look it up in your NANDA nursing diagnosis handbook.
  4. by   Esme12
    Welcome to AN! The largest online nursing community!

    What care plan book do you use? Do you have the NANDA I for current nursing diagnosis terminology and characteristics?

    Care plans are all about the patient has given this the only problem she has? Waht thisher first child? Was it a vaginal birth or C-section? Does you patient have a tear? DO they have an episotomy? Are they breast feeding? How long was labor? Did they have an epidural?

    You are falling into the same trick bag that all students fall into.....picking you diagnosis and trying to fit the patient into it......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 the diagnosis.

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing 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.

    Every nursing diagnosis needs to be an approved diagnosis statement from NANDA I.....GrnTea says it best....
    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. Evaluation (determine if goals/outcomes have been met)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1.

    Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

    What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

    Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

    This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

    Now......Tell me about your patient.......What do they need? What do they c/o? What is your assessment? What is your patient saying? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.
  5. by   Ruba
    What do you guys think? Am I missing something?
    I'm not really sure about the nursing diagnosis...

    Risk for infection related to site for organism invasion secondary to invasive procedure (episiotomy)

    1. Monitor for signs of infection (as well as teach patient sign of infection):

    • Redness, swelling, and increased pain at site of incision
    • Elevated temperature Fever of up to 38 C suggests infection

    2. Monitor white blood count. (Rising WBC indicates body's efforts to fight pathogens)

    3. Teach patient how to reduce risk of infection:

    • Educate patient proper care of perineal and vaginal area. Teach patient to clean from front to back to prevent contamination of incision. Patient may clean vaginal area with normal saline. Advise patient to keep area dry and practice frequent change in pads. Emphasize the importance of hand washing technique.

    Short Term goal: After two hours of interventions the client will be able to verbalize health teachings and demonstrate at least 3 ways on how to prevent infection

    Long term goal:
    After one day of interventions patient will remain free of infection, as evidenced by normal WBC count, temp < 38 C, and absence of foul odor from site of incision.
    Last edit by Ruba on Nov 16, '13 : Reason: Size
  6. by   Ruba
    No ABG's done. Just Platelets and WBC (which are both normal). She was quite pale, that is all. The medical staff didn't seem concerned about it. She was being released the same day. So confused!!
  7. by   Ruba
    Nursing diagnosis are my weakness! I have all the information its just putting it all together that is the problem. Thank you so much !

    This is my patient's second child, vaginal birth, preterm baby (33 weeks), she had an episiotomy, she is breastfeeding, no epidural, and I believe she was in labor for 6 hours.
  8. by   Esme12
    even though the HgB is 9.9 it is not uncommon to have slight anemia postpartum. Here is the US transfusion standards are that the patient is not transfused unless HgB is less than 7. In the US we use NANDA I diagnosis statements exclusively. Anemia is not a NANDA diagnosis. Did she complain of fatigue or weakness?

    Impaired Tissue Integrity R/T episiotomy
    Acute Pain R/T childbirth/episiotomy

    Do you maternal care plans include baby as well?
  9. by   cwr923
    Thanks esme12! Great info! I am starting nursing school in Jan & plan to refer back to this. : )
  10. by   JustBeachyNurse
    Do you have a NANDA-I book ? Your nomenclature for the diagnosis statement isn't correct
  11. by   VickyRN
    Episiotomy thread merged with anemia thread, since involves same OP and same patient scenario.
  12. by   Ruba
    In my country I believe they transfuse at 8 and below (but i'm not sure). She was complaining of fatigue as well as pain in the abdomen.
    And no our maternal care plans don't include the baby.
  13. by   lwhatley
    My only suggestion to you for now is that you have to look at your assessment, step back, and look at the big picture.

    For a second, forget about the fact that you have to find an official diagnosis and just run through what you think this patient needs addressed...

    This pt is postpartum with her second child...this means multiple things that could be helpful in developing a plan...the most obvious being the pain/stress r/t child birth, the fact that she is now a mother of two children..what's her support system like? Have you asked her about it? Have you asked her about her plans after discharge? Is there any significant psychosocial factor that needs to be addressed in order to ensure the healthiest patient you can produce? You just said she complained about fatigue, and abd those are things that your patient is actively having a problem with...

    Now lets dig deeper...this patient just went through child birth...with even a basic understanding of the physiological process in play, we realize that her body was just under a significant amount of stress, and that is AFTER undergoing 9 months of the biologically stressful development of another life listed off labs, well, one lab, hemoglobin, and pigeon holed yourself in your thinking by automatically associating it with anemia...not so fast! H&H levels are only one piece in a nursing diagnostic puzzle. Keep in mind what you said in earlier and later posts..."complaining of fatigue"..."looked pale"...alright, you're starting to build a good defense for a later nursing diagnosis...

    But first, ask your self if this lab result is expected or unexpected? Keeping in mind her recent events...(hint: expected decrease in H&H r/t child birth...) Don't narrow your vision of the patient based on one FRAGMENT of her overall assessment. Remember, a nursing diagnosis is going to drive the direction in which you base her entire care! If you still wanna run with it, you've gotta build a better case than just pointing to a lab value and making it your mission to correct it....(hint: your reports of skin color and fatigue are useful here)

    Without even realizing it, you've built a case for a prioritizing a nursing dx regarding inadequate perfusion, and you've got that assessment data to back it up...maybe take that into consideration?

    But as I said in the beginning, make sure you don't neglect the bigger picture, if your assessment data points to a psychosocial issue r/t this new addition to the family, or the foreseeable implications her healing process will have on her future post discharge, it might be worth while to focus on those in your plan of care as well...

    As for your attempt to prioritize targeting risk of infection r/t an episiotomy, think of it this way: Pt had an episiotomy, were there any complications in this procedure? Do lab results indicate any evidence of a possible infection? Does the site look worrisome? If not, remember that this is a pretty standard/common procedure in the OB world, so unless there is a red flag present from the procedure, this isn't all that relevant to target as a care priority, it's important to see to good wound care, but leave that to the priority of your teaching before discharge...
  14. by   lwhatley
    In addition, I happened to have written a very long term paper in my OB clinical regarding the care of a postpartum patient fairly similar (mainly in that she had a critical H&H)...just to give you some strategy ideas, I'll show you the list of nursing dx's I listed off that applied to my pt...I used this list to pick one specific dx to then complete an extended care plan...have at it yo' see if it inspires you to develop applicable ones for your own pt...

    - Activity intolerance r/t fatigue secondary to anemia A.E.B pt report of light headedness, headache, dizziness upon standing.
    - Fatigue r/t labor A.E.B physical assessment and patient observation of activity intolerance.
    - Sleep Pattern disturbed r/t hospitalization A.E.B observed spurratic sleep pattern and lack of ability to attain adequate sleep.
    - Transfer ability, impaired r/t incision secondary to C-section A.E.B facial grimace and refusal to move without pain meds.
    - Risk for bleeding r/t birth A.E.B lochia characteristics and clot extraction.
    - Cardiac output, decreased r/t anemia A.E.B altered vitals
    - Moderate anxiety r/t transfusion indications A.E.B frequent questions of risk.
    - Fear of transfusion r/t associated risks A.E.B patient's report.
    - Risk for constipation r/t pharmacological therapy A.E.B lack of BM, iron supplement indications, pain medication orders.
    - Breastfeeding effective r/t proper training A.E.B successful feeds.
    - Anxiety r/t breastfeeding A.E.B lack-of-confidence in ability.
    - Risk for electrolyte imbalance r/t anemia and blood loss, A.E.B altered labs.
    - Risk for deficient fluid volume r/t breastfeeding A.E.B lack of supplemental intake.
    - Comfort impaired r/t hospitalization A.E.B irritability
    - Acute Pain r/t birth secondary to c-section A.E.B reports of pain
    - Gas exchange impaired r/t anemia secondary to blood loss as evidenced by altered perfusion.
    - Risk for imbalanced body temperature r/t loss of blood secondary to birth A.E.B vital sign changes.
    - Risk for contamination r/t blood transfusion secondary to critical H&B
    - Risk for falls r/t dizziness, fatigue, headache secondary to anemia.
    - Risk for infection r/t surgical incision secondary to C-section.
    - Risk for infection r/t blood transfusion secondary to critical H&H.
    - Risk for injury r/t blood transfusion
    - Impaired skin integrity r/t surgical incision secondary to C-section.
    - Impaired tissue integrity r/t surgical incision secondary to C-section.
    - Knowledge, procedure and risks of blood transfusion, deficient r/t anemia and critical H&H.