Maternity Nursing diagnosis for OBGYN Clinical PDF

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Maternity Nursing diagnosis for OBGYN Clinical...

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Maternity/Newborn Nursing Diagnosis How to prioritize when choosing a nursing diagnosis 1. 2. 3. 4. 5. 6.

List the patients issues/problems after completing your worksheet Ask yourself which problem or issue is more important? Why?

Ask yourself what is most important to the patient. Decide if they are real or potential problems-Real problems take priority Decide if they are acute or chronic problems-Acute problems take priority Decide if they are physical or Psychosocial problem (hint pain is psychosocial)Real physical problems take priority over Real Psychosocial problems 7. Do any of the problems effect the patients airway, breathing or circulation?These problems take priority

Newborn Nursing Diagnosis 1) Ineffective breastfeeding (** can also be a maternal diagnosis)    

Poor latch, latch scores less than 8 Pain during breastfeeding Significant weight loss in a breastfed baby 10% or greater Decreased output in a breastfeed baby

2) Ineffective infant feeding pattern 3) Imbalanced nutrition: less than body requirements

4) Risk for Neonatal Jaundice     

RH neg mother Coombs positive Preterm/Late Preterm Increased weight loss Breastfed infant

5) Ineffective Thermoregulation (Risk for)   

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Preterm/Late preterm Low blood sugars Documented low temperatures Small for gestational age or IUGR infants

6) Nutrition Imbalance 

Poor weight gain

7) Risk for sudden infant death syndrome

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Teen parent Maternal smoking Smoking in the household All newborns

8) Risk for unstable blood glucose level     

Infant with Low temperatures Small for gestational age infants Large for gestational age infants Infants of a Diabetic mother Jittery infant

9) Risk for imbalanced body temperature 

Infant consistently not swaddled or dressed appropriately

Maternal Diagnosis 1) Bleeding (Risk for)          

Vaginal delivery or C-section Postpartum Hemorrhage after birth Retained placenta Boggy fundus Circumcision (newborn) Vacuum or forceps delivery Use of magnesium sulfate during labor Infection Multiple birth Vaginal Hematoma

2) Constipation (Risk for)     

Decreased bowel sounds C-section A patient that refuses to ambulate Narcotic use Episiotomy

3) Infection (Risk for) *** could also be used for newborn      

Increased temp (newborn and maternal) GBS + (newborn) Meconium stained amniotic fluid (newborn and maternal) Prolonged rupture of membranes > than 12 hours (newborn and maternal) C-section Episiotomy/Laceration repair

4) Impaired urinary elimination (Risk for) *** could also be used for newborn

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Recent foley catheter removal Epidural or Spinal Vaginal or C-Section delivery Post circumcision (newborn)

5) Ineffective airway clearance (Risk for) *** could also be used for newborn  

Post op C-section Recently delivered newborn (newborn)

6) Impaired tissue perfusion (Risk for)    

Preeclampsia HTN Hypotension DVT

7) Insufficient Breast Milk 

Mom not making enough milk

10) Interrupted breastfeeding

Psychosocial diagnosis Anxiety Impaired parenting (risk for)   

Single parent Lack of resources (financial, social etc.) Teen parent

Depression (Risk for)   

History of anxiety or depression NiCU baby Traumatic delivery

Impaired comfort   

Labor Episiotomy Laceration

Acute Pain    

Labor Circumcision Post-delivery Episiotomy or laceration

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Vaginal Hematoma

Dysfunctional family processes Risk for disturbed maternal-fetal dyad

Labor and Delivery Specific Ineffective Childbearing Process Risk for Ineffective Child Bearing Process

Readiness for Don’t forget there are Readiness or Wellness Diagnosis- Assessing a patient's readiness to respond to a wellness diagnosis involves patient interviews and interaction. These only involve one part no r/t or aeb. Examples.. Readiness for enhanced immunization status, Readiness for enhanced parenting…. Readiness for enhanced breastfeeding, Readiness for enhanced childbearing process, Readiness for enhanced organized infant behavior...