OB careplan help

Daytonite, BSN, RN · Sep 18, 2009

a nursing problem (nursing diagnosis) is always based upon evidence that you have to support that it exists.

the construction of the nursing diagnostic statement

follows this format:

p (problem) - e (etiology) - s (symptoms)

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

acute pain aeb reporting a 7 on a 1-10 pain scale

"reporting a 7 on a 1-10 pain scale" is a symptom so it belongs in the aeb spot.
women also have afterpains (contractions of the uterus)
it you look at a nursing diagnosis reference (the taxonomy--there is one in the appendix of taber's) you will get the idea that the related factors for this particular nursing diagnosis (acute pain) have to do with things that damage or cause damage to the tissues. this is where your knowledge of pathophysiology has to come in. what happened during the birth? that baby stretched and tore her lady partsl tissues as it came through the birth canal. what happens when any skin or tissue is damaged? it begins to heal and the inflammatory response is set into motion. the four cardinal signs of the inflammatory response are (each one leads to the next): heat, redness, swelling and pain. it can easily be seen in a boo-boo on the surface of the skin, but not so easily when the tissues are internal, but i assure you this is going on. now, think about all the structures close to the birth canal that will be affected by the inflammatory response depending on how strong it might be and how they will respond: the bladder, the rectum. that's where the potential problem of urinary retention comes from.
acute pain r/t birth trauma aeb reporting a 7 on a 1-10 pain scale

is she breast feeding? there is a diagnosis for normal breastfeeding.

was she dehydrated after labor and need fluid replacement? most women do even though they have had ivs.

was she fatigued and tired after labor? most are and need a lot of sleep and rest.