Postpartum careplan - does this dx work?

Daytonite, BSN, RN · Jul 25, 2009

So, let me understand this. . .she is not breastfeeding. . .at all, right? If that is the case, then you can't use Ineffective breastfeeding r/t maternal breast anomaly and previous history of breastfeeding failure AEB client self-report. That is a misdiagnosis. A breast anomaly is something physically wrong with the shape of the breast. Ineffective breastfeeding is only used when the mother is breastfeeding, but is having problems with it. The definition of this diagnosis is dissatisfaction or difficulty a mother, infant, or child experiences with the breastfeeding process. If she's not even breastfeeding and this baby is being fed by means other than the breast then you can't use this diagnosis. Breastfeeding is very fatiguing and painful for some mothers which is sometimes why they don't want to do it after their first experience.

CharleeJo.RN · Jul 25, 2009

Ok, that makes sense. Thank you very much!! It's under nutritional/metabolic pattern, so I will go with impaired skin integrity r/t cesarean incision.

Speaking of which...would I want to go with impaired SKIN or impaired TISSUE integrity in regard to the incision?? I'm thinking tissue?

Daytonite, BSN, RN · Jul 25, 2009

Impaired Tissue Integity. Read the definition and you will see the difference between the two.

CharleeJo.RN · Jul 26, 2009

DAYTONITE...i need your help!!! i read a *ton* of your other posts but a lot of the links you had were either outdated (not there anymore), you had to be a subscriber, or it wasn't what i needed.

I have a headache and I'm ready to cry and pull my hair out...this postpartum care plan is slowly killing me.

We need to have a thorough HEAD-TO-TOE assessment of the mom - everything imaginable that can be assessed in a human being. However, for the life of me, I cannot find anywhere - amongst the many medical books at my house or on the internet or this site - that has a thorough head-to-toe assessment for a postpartum woman (typical changes in a postpartum woman head-to-toe).

I know you must have the answer. Please, please, please...I would appreciate it more than you can imagine if you can point me in the direction of a thorough outline of physical & physiologic changes in the postpartum woman. I can't even find it in my OB text!!

Thank you soooooooooooooooooooooooo much!!

Daytonite, BSN, RN · Jul 26, 2009

this should help. . .i do not have a head-to-toe assessment, but i do have an assessment data base from maternal/newborn plans of care: guidelines for individual care, 3rd edition, by marilynn e. doenges and mary frances moorhouse based roughly on gordon's functional health needs of the normal and abnormal data that you are likely to find for a c-section patient following a c-section. you can pull the information apart and re-classify by head-to-toe. it is on page 331 of the book:

circulation

blood loss during the procedure approximately 600-800 ml

ego integrity

may display emotional lability, from excitation, to apprehension, anger, or withdrawal.

client/couple may have questions or misgivings about role in birth experience.

may express inability to deal with current situation.

elimination

indwelling urinary catheter may be in place; urine clear amber.

bowel sounds absent, faint or distinct.

food/fluid

abdomen soft with no distension initially.

mouth may be dry.

neurosensory

impaired movement and sensation below level of spinal epidural anesthesia.

pain/discomfort

may report discomfort from various sources, e.g., surgical trauma/incision, afterpains, bladder/abdominal distension, effects of anesthesia.

respiratory

lung sounds clear and vesicular.

safety

abdominal dressing may have scant staining or may be dry and intact.

parenteral line/saline lock when used, is patent, and site is free of erythema. swelling and tenderness.

sexuality

fundus firmly contracted and located at the umbilicus.

lochia flow moderate and free of excessive/large clots.

diagnostic tests

cbc, hb/hct:

assesses changes from preoperative levels and evaluates effects of blood loss in surgery.

urinalysis (ua); urine, blood, lady partsl and lochial cultures:

additional studies are based on individual needs.

here is the assessment information for the c-section care plan on the disc of care plans that accompanies the book nursing care planning made incredibly easy:

assessment (only potential abnormalities listed)

nursing history by functional health pattern

(these are check off items)

health perception and management

feelings of loss of lady partsl birth experience

nutrition and metabolism

hunger

thirst

elimination

constipation

urinary retention

activity and exercise

difficulty ambulating

cognition and perception

incision pain

fear regarding the well-being of the baby

sleep and rest

fatigue

sexuality and reproduction

dissatisfaction with route of delivery and longer recovery time

physical examination

general appearance and nutrition

generalized edema

mental status and behavior

fatigue

integumentary

incision on lower abdomen

respiratory

shallow respirations

cardiovascular

possible bradycardia

possible hypotension

gastrointestinal

hypoactive bowel sounds, initially

hyperactive bowel sounds

musculoskeletal

immobility of the lower body until anesthesia wears off

renal and urinary

indwelling catheter

reproductive

lochia

uterine tenderness

fundal height at or below the umbilicus, decreasing over time

enlarged, tender breasts

diagnostic studies

pelvic ultrasonography estimates gestational age and fetal maturity.

complete blood count evaluates hemoglobin level and hematocrit.

blood typing and crossmatching reveal rh status and blood type.

electrolyte studies reveal abnormal sodium, potassium, chloride, and carbon dioxide levels.

coagulation studies reveal clotting abnormalities that can increase the risk of hemorrhage.

urinalysis screens for a possible urinary tract infection.

electronic fetal monitoring detects signs of fetal distress.

maternal complications of c-section (this information is needed for care planning)

bowel, bladder, or uterine injury
hemorrhage
genitourinary tract infection
paralytic ileus
respiratory tract infection
thromboembolism
wound dehiscence

CharleeJo.RN · Jul 26, 2009

Has anyone ever told you how fantastic you are?!? Thank you!! This is a lot of help. I think I was just looking too much into it last night; i have a tendency to over-analyze everything. Once I simplified things and just thought of the obvious, it all became much easier.

Once again, thank you for your help. It is MUCH appreciated =) Bless you!

Daytonite, BSN, RN · Jul 27, 2009

I have had 30+ years as a nurse to figure this stuff out. Believe me, I was not a stellar student.

There is a great deal of logic and reason in all of this. What you need to do is look at this assessment data (it includes history and physical exam information) and see how it is similar as well as different from, lets say, a regular old surgical patient that you might have had a semester or two ago. A C-section is a surgery. Some things are similar to what you assessed and looked for in surgical patients and you can build on that knowledge. Other stuff is specific to an OB patient and you need to note exactly what it is and think about why that is important. Think about what the OB patient experiences and what the presence of a fetus has on the mother's body and that is going to explain why that abnormal assessment data came to be. Make those connections so it all sticks in your mind because it is very logical and reasonable that it has happened and came into existence.

Now, do you think you can assess for a mother who has delivered lady partslly? A baby coming through the birth canal puts a lot of pressure and trauma on the surrounding parts of the mother's body. It is not quite correct when people say that the birthing process is "normal". Labor and delivery is like getting beat up internally and no one being able to see it from the outside. I ask because you will probably need to know this kind of information for your test(s) at school and for the NCLEX. I am trying to help you do some critical thinking here.