OB nursing diagnosis

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hey! am working on my careplan and am having a hard time coming out with a nurisng diagnosis for a a pregnant patient who didnt take a prenatal class.....any help will be appreciated! THANKS!

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Specializes in General adult inpatient psychiatry.
hey! am working on my careplan and am having a hard time coming out with a nurisng diagnosis for a a pregnant patient who didnt take a prenatal class.....any help will be appreciated! THANKS!

Maybe some sort of knowledge deficit related to infant care?

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

that's all the data you have to share: pregnant patient who didn't take a prenatal class? what kind of questions did you ask this patient? what data did you get back? any diagnosis is based upon evidence (signs, symptoms, abnormal assessment data) that you have collected. you have to consider that information. you won't hear of a doctor determining a medical diagnosis for a patient until they have questioned, examined and probably done tests on the patient. to determine nursing diagnoses we do similar activities:

  • a history and physical assessment of the patient
  • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease/condition
  • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
  • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

see this thread for more information on how to write a care plan:

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THANKS!

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