Published Apr 2, 2014
Pt. Info: 22 year old, G3P3, repeat c-section with intrathecal analgesia at 21:52 on 3-27 (I gave care on the 28th), dermabond to incision. GBS negative, Rubella immune. NKA. Pt. has been given phenergan and zofran for nausea. Pt. has venodines and foley cath. IV D5/.45 NS @ 125mL/hr. Vitals normal. Fundus firm, midline, moderate lochia rubra. No redness, swelling to incision. Incision edges well approximated. Urine output normal. Bowel sounds present in all 4 quadrants. Lungs clear bilaterally.Breasts full, colostrum present, pt. is breast and bottle feeding. Clear liquid diet. Spouse present at bedside. Pt. wants to ambulate and is eager to go home.
I need help with my wellness diagnosis and interventions.
Readiness for enhanced self-care, able to ambulate with assistance.
I following an example from Nursing Dx. Handbook by Betty J. Ackley, but I feel like the last part isn't right. I'm not quite grasping the "action or health-seeking behavior that will be enhanced" part.
1. Assess patient's balance and ability to ambulate (Teacher wants assessment first)
2. Set goals with the patient
My book doesn't spend a lot of time on c-sections, so I'm not sure what is realistic for this patient or what types of teaching (even for long term) I could give to her. Maybe do not lift objects heavier than the baby?
Any help is appreciated.
The patient has a surgical incision.... what does that put her at risk for? She needs to learn how to care for the incision and recognize any complications. She is recovering from surgery. She will likely need to enlist help from friends and family. Another intervention would be to have the patient list people she can rely on to help her with the baby so she can get adequate rest during her recovery.
Esme12, ASN, BSN, RN
First of all, let's work through the pathophysiology of what is going on with this patient. A patient who has had a C-section has had a surgery where some sort of anesthesia was used (I'm assuming an epidural).
What are the common complications for the type of anesthesia that was used and was the patient thoroughly assessed for any of the symptoms of them? When there is any kind of trauma, even the smallest boo-boo, the body responds by initiating protective protocols. The result is the local tissues swell as the blood supply to the area increases. Swollen tissues create some problems, particularly if they are pushing against other tissues and organs. So, you have to keep in mind the organs that are contained in the pelvic area that are subject to this (urinary bladder, part of the large intestine, genital organs). With surgical intervention these same protective responses of the body are going to be initiated because there has been a foreign invasion by the surgeon with mechanical manipulation of the tissues.
Here is a list of the common complications of surgical patients undergoing general anesthesia:
Complications of epidural anesthesia are:
You have a incision. Impaired Skin Integrity R/T surgical intervention is an appropriate diagnosis to use. Your nursing interventions under this diagnosis would include monitoring and care of the surgical incision.
Constipation should be considered a problem due to swelling of the internal tissues until the patient passes their first stool. If your patient is not passing gas, then it is likely that she is going to be constipated considering the amount of narcotics she got during the C-section. Likewise, until the patient is voiding adequately, urinary problems need to be watched for. If the mother was in labor before the C-section and doing some pushing, there may be hemorrhoids that need attention.
If the mother is breastfeeding, there are several nursing diagnoses that address this for both the mother who is breastfeeding without problems and those who are having problems: Effective Breastfeeding, Ineffective Breastfeeding, and Interrupted Breastfeeding.
Was there blood loss during surgery? What was the patient's fluid status prior to surgery? What about after surgery? Were there any food or fluid restrictions? The consideration of a nursing diagnosis of Deficient Fluid Volume is most appropriate.
With surgical invasion there is often Acute Pain.
After labor and delivery and/or C-Section mothers are usually pretty fatigued. There is a nursing diagnosis for this: Fatigue.
If you really want to get fancy there are also these nursing diagnoses:
I have to use a wellness diagnosis.
Well look at your NANDA resource ans see what applies to your assessment.....A WELLNESS DIAGNOSIS....Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement.” Examples of wellness diagnosis would be Readiness for Enhanced spiritual Well Being or Readiness for Enhanced Family Coping.
There are always adjustments to bringing a baby home. Things that people want to make better
Readiness for enhanced immunization status
Readiness for enhanced self-care
Would be two that could apply here
Care plans are all about the assessment...of the patient. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.
The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.
Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.
Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.
Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.
Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.
Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite
Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.
Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.
A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.
What I would suggest you do is to work the nursing process from step #1.
Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.
What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.
Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.
This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.
Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.
Another member GrnTea say this best......
What about teaching patient care of incision, teaching s&s of infection, when to call doctor, nutritional education to aide healing, teaching cough and deep breath using is, splinting...?
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