Prioritizing Postpartum Dx'es

[gatorina]

Writing care plans for 18 hr pp patient, C-Section: EBL=700 mL. Moderate lochia, fundus firm at U. Incision approximated & no REED. Heart sounds regular & strong, lungs clear, bowel sounds present, no edema, Labs all normal, I/Os all within normal range, v/s within normal. Pt up to ambulate to restroom & shower, no postural hypotension. IV dc'ed, Foley dc'ed. Incentive spirometer used regularly. Patient has hx (familial & personal) of anxiety (rx for BuSpar) depression (Lexapro) & HTN (Labetalol). BMI is 31. Determined to breastfeed, no education re. this topic, displays (subjective & objective evidence) considerable anxiety re breastfeeding & infant care. She is compliant with all meds, plenty of prenatal care. I have 6 diagnoses. I know there are more, but I need only the top 6. The top 2 are what I need to do plans on. ABCs don't seem to apply here, and "Risk for infection", while always a concern with anyone post-surg, doesn't scare me too much on this one. But still, I suppose if anything could kill her, it would be that. Argh. Am I just resisting risk for infection b/c I REALLY am tired of writing yet another risk for infection care plan? Or is my hunch correct that there are other more important issues here? Here is what I've got, please help me prioritize them:

-Ineffective breastfeeding r/t poor infant latch

-anxiety r/t stress, lack of sleep, role function, heredity

-Actute pain r/t surgical incision

-risk for infection

-deficient knowledge r/t lack of exposure to breastfeeding education

-Imbalanced Nutrition: more than body requires r/t excessive caloric intake

Postpartum is a challenge b/c drawing the line between care of infant vs mom is not always clear to me. It's like suddenly you have two patients, and when they're both largely healthy, teasing out the priorities between "lower rung" dx'es just drives me nuts!

*And yes, I understand how problematic a word like "normal" is when describing objective evidence and no I don't use that word when documenting.

[Double-Helix, BSN, RN]

-Ineffective breastfeeding r/t poor infant latch

-anxiety r/t stress, lack of sleep, role function, heredity

-Actute pain r/t surgical incision

-risk for infection

-deficient knowledge r/t lack of exposure to breastfeeding education

-Imbalanced Nutrition: more than body requires r/t excessive caloric intake

Pain would be the top priority. Pain can also cause anxiety, difficulty concentrating (if you're trying to teach her), and difficulty breastfeeding (due to the pain while positioning). It can be the root of a lot of issues.

I was always taught that risk diagnoses have lower priority than actual diagnoses, but I'm not always sure I agree. Postpartum infection is a big deal.

I'd say the ineffective breastfeeding goes before the deficient knowledge.

Do you have any evidence that she has excessive caloric intake? Is her BMI pre or post pregnancy? BMIs will be severely skewed for pregnant women. A woman of healthy weight (let's say 5'5" weighing 145) with a BMI of 24.1 will have an obese BMI of 30 after gaining a very a healthy 35 lbs during pregnancy. Weight and BMI alone are not enough to diagnose imbalanced nutrition in a pregnant woman. You need to ask about her weight history, exercise (pre pregnancy) and diet (pre pregnancy).

[gatorina]

Sorry, I forgot to mention that her BMI is pre-pregnancy and that she admitted to "exercising too little and eating too much" and wanted to start walking with her baby as soon as she was able. Trust me, I know all about pre-versus-postpartum weight... I had twins 18 mos ago! :)

And I agree generally about the "risk fors"... when ABCs are on the line... But with nothing other than the incision itself being a factor for infection... No hygiene problems, no nutritional deficits, no lack of knowledge on how to care for incision... There's just not a lot there to support it as the #1 dx. But I know, if anything on this list is going to kill her...

[classicdame, MSN, EdD]

pain is not a top priority to NCLEX. Risk of infection would be more important in this scenario. Insufficient nutrition for the baby is more important that pain for the Momma. Sorry, but we have to consider Maslow's

[4boysmama]

The IBCLC in me wants to say that the ineffective breastfeeding would be the priority diagnosis (because not only is the baby at risk with bad feeding, but mom then becomes a risk for infection from poor emptying - so risk for mastitis is huge) But...the nursing student in me says that the proper "NCLEX" response would be pain or risk for (maternal) infection...

[gatorina]

Thanks all! I went with "Ineffective Breastfeeding". I had a revelation along the lines of 4boysmama's... actual Ineffective Breastfeeding is going to be more harmful to baby than an infection that hasn't (and likely won't) happen. That's my decision, and I'm sticking with it!