Vaginal Birth: Nursing Diagnosis for mother and baby, HELP

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I need some help, my care plan book doesn't have any Maternity in it at all, how do I find nursing diagnosis without book? I need 6 for mom and 4 for baby, can anyone help me?

Wheart

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

see:

it is inappropriate to diagnose based only upon a patient's condition without having performed an assessment first. diagnoses are based upon the assessment information you obtained. not everything you observe in the mother is normal. a 6-pound (or more) baby coming through a lady partsl canal leaves trauma behind. that trauma is the basis for potential nursing problems (diagnoses). if you post your assessment information i will help you determine your nursing diagnoses.

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Mother was 41yr old, 5/4/1. She was in labor for approx. 10 hrs. when I walked in. Was dealing with labor , no drugs. Ruptured membrane at 0853am, 0930am was 9cm, 100% efaced-0 station, Started pushing at 1000, baby born at 1026am, 8lb.3oz. 20 1/2" baby boy.Mom was bleeding pretty good, when they found that the placenta was very high.Doc worked and worked to get Placenta expelled at 1037. She had a velamentous Insertio placenta. She tore a little bit but doc didn't sew, said she would be fine. Started Oxytocin/NSS 20units 125mls right away after birth. Little boy was circumcised next morning. Hopefully I have given you what you needed to know to help me. As I said before I do not have a care plan book to help me with maternity care plans. That is why I am asking for help. Sorry to bother anyone with this. Wheart

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

Nursing diagnoses are based on the patient's assessment and symptoms. The only assessment information you have provided is that the patient tore during delivery but it wasn't sutured and she lost a lot of blood. However. . .were there other signs of dehydration? Did you get a H&H? Is she having any problems urinating or having a bowel movement as a result of this tear? Was there any fatigue? Is she breast feeding? Is this her first child? Does she have any learning needs?

You need to go back and read https://allnurses.com/forums/f8/care-plans-new-mother-baby-315228.htm I posted all the diagnoses there you need for the baby.

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Thank you very much for all your help Daytonite. I really get it now, I was worried that I actually needed a Care Plan book especially for new mother/baby, but I got it now. You said I asked you back in July, well I did but this was my third rotation and finally got to see both lady partsl and c-section births. Thanks again for all your help

Wheart

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