Published Jun 3, 2009
I'm currently doing my OB clinical rotation. I've having difficulty coming up with how to word my r/t factor in my nursing diagnoses. I took about 2 semesters off now I've seem to have lost my grasp on how to do these properly. I would really appreciate any help and pointers I could get :)
Impaired skin integrity
Data: -Pt. has 1st degree laceration in perineal area from vaginal birth
-Pt. has swelling and bruising of the labia majora
-Pt. has hemorrhoids that have compressed near her anus
Risk of fluid volume deficit
Data: -Pt. loss 400ml of blood during vaginal delivery
-Pt. states that she has not been drinking many fluids
-Has drank around 720ml of fluids
-Pt. is breastfeeding
Risk for infection
Data: -1st degree laceration in perineal area
-h/h is 11.2/32
Risk for constipation
Data: -17h. post delivery and no bowel movement
-Inadequate intake of fluids
-Pain from hemorrhoids and laceration
-Abdominal pain due to contracted fundus
-Use of NAIDs
Use the data the you have posted it's really good. Risk for r/t 1st degree laceration to perineal area. Risk for constipation r/t no bowel movement 17h post delivery and so on
Sorry about the 1st one. I meant risk for infection r/t 1st degree laceration in the perineal area
Daytonite, BSN, RN
i'm having difficulty coming up with how to word my r/t factor in my nursing diagnoses. i seem to have lost my grasp on how to do these properly. i would really appreciate any help and pointers i could get.
your diagnoses have been resequenced in the correct order of priority according tp maslow's hierarch of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs) and placing actual diagnoses ahead of potential diagnoses. . .
risk of fluid volume deficit - this is not a risk if the fluid has already been lost
data: -pt. loss 400ml of blood during vaginal delivery
-pt. states that she has not been drinking many fluids - fluid must be lost in order to become a cause and symptom of this diagnosis.
-has drank around 720ml of fluids - this is an intervention and not a symptom
-pt. is breastfeeding - this is an interesting piece of assessment, but not a symptom
-h/h is 11.2/32
impaired skin integrity
data: -pt. has 1st degree laceration in perineal area from vaginal birth
-pt. has swelling and bruising of the labia majora
-pt. has hemorrhoids that have compressed near her anus - this is not a symptom of impaired skin integrity unless they are open and bleeding, oozing some kind of drainage. if they are causing pain, then diagnose acute pain.
risk for constipation
data: -17h. post delivery and no bowel movement
-inadequate intake of fluids
-pain from hemorrhoids and laceration
-abdominal pain due to contracted fundus
-use of naids
risk for infection
data: -1st degree laceration in perineal area
-h/h is 11.2/32 - this is a symptom of deficient fluid volume (above)
-pt. has swelling and bruising of the labia majora - swelling is evidence of the inflammatory response, not infection; bruising is evidence of rupture of blood vessels and bleeding into local tissues.
- is wbc count low after delivery?
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