OB Care plan help

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I need some advice with my Nursing Dx for my postpartum patient. She is a 25 y/o, she had a vag. delivery at 39 wks. Her hemoglobin was 7.4 and her HCT was 23.7. She fall 24 hrs after her delivery trying to go to the bathroom; her BP was 98/63. She was also positive for GBS. I was thinking about choosing "Risk for Injury" for my Nursing Dx. Can anyone please let me know if this is a proper Dx for my patient or does someone have something better in mind.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Since she already fell once, she's a Risk for Falls. More so, with a HBG of 7.4, and I'm guessing she probably had dizziness although you didn't mention it, she probably has blood loss anemia so she probably has Deficient Fluid Volume. You need to check your assessment information to verify that this is true. Did she have an episiotomy? If so, she has Impaired Tissue Integrity. Is she breastfeeding? There is a diagnosis for that as well. What do you mean by positive GBS? There are a number of diseases that are abbreviated as GBS. Break it down into its symptoms. If she is manifesting symptoms that are causing problems, then develop nursing diagnoses for the individual symptoms.

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Specializes in Critical Care-Neuro/Trauma ICU.

I had a patient similar to this and I used Deficient Fluid Volume r/t blood loss AEB low hemoglobin levels. I also used Anxiety r/t unexpected blood loss and uncertainty of outcome AEB patient's statment "......". We were actually required to include one psychological diagnosis for our postpartum patients. Hope this helps!!

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Yes it does help, thank you so much. :wink2:

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GBS=Group B strep infection

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