OB Care Plan

[liltam7]

My newborn patient is healthy but im trying to find a "risk for" nursing diagnosis. She is bottle fed, maybe anything related to this?

The mom has cellulitis, is impaired tissue integrity a good diagnosis? Any suggestions for interventions?

[Daytonite, BSN, RN]

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.

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

)

.

the underlined blue type are a weblinks to nursing diagnosis pages with nanda information and some goals and nursing interventions.

for the mother:

there are 3 breastfeeding diagnoses:

effective, ineffective

and

interrupted

. does one apply to the mother? diagnoses are based on the symptoms that a patient has. cellulitis is a medical diagnosis. break it down into its signs and symptoms. do any of them fit into the signs or symptoms or a nursing diagnosis? the defining characteristics (signs and symptoms) of

impaired

skin

integrity

are listed here:

impaired skin integrity

. it also includes some interventions. for specific interventions for mastitis, see the ob weblinks on this thread:

https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html

[liltam7]

Thank you.

For the baby, i wanted to use risk for infection but its going to be related to extrauterine exposure ... im not really sure about it. The baby's umbilical cord is dry and intact, so i can't really use it as a related to factor. Im also having a hard time how to create the pathophysiology.

The mom will be impaired skin integrity r/t to inflammation of subcutaneous tissue AEB affected area warm & tender to touch, swelling, redness and protectiveness to site. How does this sound? Interventions will be (1) keep the surgical incision dry, clean & intact by checking for drainage & cleaning with normal saline every 12 hours.(2) administer antibiotics as ordered (3) keep head of bed elevated @ a 30 degree angle in order to prevent pulling the edges of the incision, thus making surgical staples intact and promote faster healing.

Im still having a problem with the baby's diagnosis. Please give me some advise on my interventions...

[Daytonite, BSN, RN]

the baby is at a risk for infection because the umbilical cord stump is an area where bacteria can enter. for interventions, see the pediatric weblinks for baby care on https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html

when did this mother suddenly develop an incision?

if you are going to say that the subcutaneous tissue of the breast is inflamed then you must use impaired tissue integrity. the related factor is inflammation. so, your diagnostic statement should be written as impaired tissue integrity r/t inflammation aeb pain, swelling and redness of breasts. in the ob links on the thread above you can find information and care for mastitis.