Nursing Diagnosis for Postnatal Mothers

NURSING DIAGNOSIS FOR POSTNATAL MOTHERS List of Nursing Diagnosis:  Acute pain related to soft tissue injury secondary to episiotomy as manifested by mother’s verbalization and pain scale showing 5/10.  Anxiety related to parenting responsibility of newborn as manifested by mother’s verbalization and frequent enquiry about newborn care.  Activity intolerance related to episiotomy pain as manifested by mother’s dependence on others for doing her activities.  Imbalanced nutrition less than body requirements related to increased need with lactation as manifested by weight loss, decreased food intake and poor milk ejection.  Impaired skin integrity related to tissue trauma from child birth as manifested by episiotomy and poor abdominal tone.  Sleep pattern disturbance related to physical discomforts and newborns feeding needs as manifested by irritability, looking tired and drowsy.  Knowledge deficit regarding newborn care related to lack of previous experience as manifested by frequent questioning.  Risk for postpartum hemorrhage related to labour process and atony of the uterus.  Risk for fluid volume deficit related to decrease oral intake and blood loss.  Risk for urinary retention related to postpartum edema.  Risk for constipation related to inadequate food intake, fluid loss and decreased bowel motility.  Risk for infection related to tissue trauma from child birth and breast complications.  Risk for thrombophlebitis related to changes in the blood constituents.  Risk for postnatal depression related to changes in the life style.  Risk for impaired breast feeding related to lack of experience due to first pregnancy.  Risk for ineffective newborn care related to lack of previous experience.  Risk for ineffective sexuality pattern related to postpartum discomforts, decreased sexuality of mother, fatigue.  Risk for impaired parent-infant attachment related to anxiety. Assessment Nursing Diagnosis Objectives Intervention Rationale Expected outcome  Assess the pain level of the mother Subjective Acute data: related The mother soft verbalizes injury that she has secondary to as evidenced pain in the episiotomy by mother’s episiotomy as verbalizatio sutured site. manifested n and pain pain The mother to will be and the factors relieving or  Enables to facilitate nursing care aggravating the pain.  Increased bleeding and swelling at comfortable tissue experiencing  Assess episiotomy incision for the reduced pain evidence of bleeding or hematoma by mother’s scale formation. and The mother scale looked showing leave on for 15-20min and off for 15- restless and 5/10. 20min pain scale shows the level of 5/10. to verbalizes the no pain and pain scale showing  Cold provides local anesthesia, decreased  Provide comfortable position to the data: the bladder adds discomforts verbalization showing level. increases pain and discomfort  Promotes comfort. Objective pain decreased is the site of episiotomy laceration and  A full  Assess for urinary retention Mother mother. helps to prevent perineal edema.  Apply ice pack to the perineum immediately cause local vasoconstriction and level after child birth then  Provides comfort and enhance feeling of well-being for relief from episiotomy pain  Exhaustion from labour and birth interfere with the ability to cope  Provide perineal care and sitz bath.  Encourage adequate rest and sleep in with pain and discomfort.  Diverts from the feel of pain. between the activity.  Provide diversional therapy  Administer analgesics physician’s order. with the  Reduces pain by blocking the pain pathway. pain. of Assessment Nursing Diagnosis Subjective Anxiety data: related Objectives The mother to will identify The mother parenting source of Intervention  Assess the anxious level of the mother and fears about of information newborn report feeling less of anxious the manifested newborn. as by mother’s evidenced verbalization by Objective and frequent verbalizatio data: enquiry n and The mother about confidence looks in newborn newborn anxious and care. asks doubt frequently  Enables to facilitate nursing care partner providing about the care of outcome Mother has relieved from factual parenting and  Helps ensure that an emotional sources of reaction is in response to real anxiety and rather than an imagined situation newborn care. reassurance was  Encourage the mother to ventilate her provided.  Reduces anxiety feelings. Mother is  Clear all the doubts of the mother.  Builds trust and anxiety reduction. actively  Demonstrate various aspects of newborn  Knowing what to expect helps the participating care and ask the mother to re- mother and family to provide in new born demonstrate. essential newborn care.  Use therapeutic communication to create a open relationship with the  Promotes trust and care. relieves anxiety. parents about newborn. care. Expected and the reason for anxiousness.  Discuss the situation with the mother says that she responsibility anxiety and taking care as Rationale  Develops confidence that she  Show her the mothers with similar situation and how they manage such situation. could also cope up with the situation like others. Assessment Subjective data: Nursing Diagnosis Activity intolerance The mother says that she related to Objectives The mother will activity level within usual by herself. manifested by mother’s Objective dependence The mother on others for is dependent doing her on others for doing her routine work. activities. Rationale mother’s activity intolerance to set maintained realistic goals. her  Helps to remove thee hindrance. activity level. Pain is reduced  Monitor pain score and vital signs  Identify pain and increase in heart mother capacities as evidenced  Encourage to take well balanced diet. by daily activities. comfortable. and Participating may indicate cardiac  Encourage the mother to take adequate  Provides adequate energy and rest.  Keep all the needed articles near the mother. nutrient to meet the increasing in score is 0/10 demand.  Saves energy and reduces tiredness. activities until energy level returns to  Reduces the risk of fall and loss of energy.  Encourage the mother to do postnatal exercises.  Strenuous activity will utilize more energy and may have chance for wound gapping.  Prevents hazards associated with immobility activity. REEDA  Teach the mother to avoid strenuous  Reduces unnecessary strain. normal. is rate of 20-30beats are abnormal compromise participating in data:  Analyze the factors that hinder the activity of the mother. her routine work Expected outcome  Assess the mother’s ability to ambulate  Helps determine the extent of theMother has and perform self-care activity. maintain couldn’t do episiotomy pain as Intervention Subjective data: Mother says that she does not feel like eating, unable drink fluids, discomfort. Objective data: Loss of appetite, fluids only in 1st post postnatal day, dry skin and oral mucosa, weight loss, dull and tired. Imbalanced nutrition less than body requirement related to increased need with lactation as manifested by weight loss, decreased food intake and poor milk ejection. Mother will maintain adequate nutritional status as evidenced by weight gain, active participation in the care.  Assess the dietary pattern using 24 hours recall.  Evaluate current weight  Review Hemoglobin , haematocrit and assess for pallor and fatigue  Assess the ability to meet nutritional needs.  Teach the basic food group and stress the need for protein , calories, vitamin c and calcium.  Teach calorie requirement  Explain about the need for vitamin and calcium supplements.  Refer for nutritional counseling if necessary.  Help the client to plan and diet that includes of foods especially fresh and slightly processed foods.  To determine the need for and changes in present diet  Average weight loss at delivery is 10-12 pounds.  To assess for anemia. Reduced Haemoglobin can slow the healing process.  Financial, knowledge and cultural issues may interfere with adequate nutrition.  Eating a variety of foods from each of the food group helps to ensure a balanced diet.  Lactating women need about 500-800 more kcal/ day than their non pregnant intake.  Protein is needed to promote tissue healing and regeneration. Vitamin c is needed for cell wall synthesis and iron absorption.  May be necessary to meet individual needs.  Stressing variety is a more positive approach than contamination junk food and is more likely to encourage compliance with a diet containing necessary nutrients.  Increases the likelihood of compliance with the suggested diet. Mother has achieved and maintained normal nutritional status after taking balanced diet and has improved her hemoglobin level. Objective data: Irritation, laceration, lochia rubra is present, REEDA score is 0/10 Episiotomy suture is present , vital signs Impaired skin integrity related to tissue trauma from child birth as manifested by episiotomy and poor abdominal tone. Mother will  Review labour and birth record for attain presence of risk factors like forceps normal skin assisted birth, precipitate labour and long integrity as second stage. evidenced  Assess the perineum and episiotomy Q15 by normal mts for first hour then Q 30 minutes for 1 healing, hour and then hourly REEDA score  Assess for signs of unrepaired laceration.  Assess for severe perineal pain or intense pressure  Monitor vital signs and REEDA score  Apply ice pack to the perineum , leaving on for 15 – 20 mints and off for 15- 30 mints alternatively  Provide frequent pad changes and perineal care using front to back techniques until the women is able to  To identify whether the women is at higher than normal risk for trauma to the perineum.  To determine the presence of edema , hematoma, laceration, episiotomy edges. Edema may cause the episiotomy edges to separate.  A slow trickle or bright red blood in the presence of a firm uterus may indicate unrepaired laceration.  These are symptoms of hematoma formation . pain is caused by tissue hypoxia secondary to pressure of blood accumulation within the tissue.  Elevate pulse and decreased blood pressure in the presence of firm uterus and no visible excess blood loss may be signs of hematoma formation.  Decreases the formation of edema and ecchymosed by constricting local blood vessels and facilitating clotting.  To remove a warm moist medium for growth of pathogens and avoid transferring of Ecoli. Mother has attained adequate skin integrity. Episiotomy wound is healed. Vital signs and abdominal tone normal. Assessment Nursing Diagnosis Subjective data: The mother says that she does not know to care for her baby Objective data: The mother asks doubts frequently about the bath and other care of the baby Knowledge deficit regarding newborn care related to lack of previous experience as manifested by frequent questioning. Objectives care for her. Intervention Rationale Expected outcome Mother will  Assess the knowledge level of the mother again and the ability to understand and follow adequate instructions.  Observe the ability to perform infant bathing, knowledge regarding diapering , cord care. newborn care as evidenced  Observe response to infant cue by active car of newborn  Assess parent and infant attachment.   Teach baby bath, diapering and demonstrate to the mother.  Teach the need for well baby checkup.   Refer to community resources as appropriate   Provide positive feedback when care is carried out correctly.   Involve partner and family in care of the new born        Explain about the importance of breast feeding.  Explain about immunization schedule. To determine the level of knowledge and how to proceed with teaching regarding infant care. To determine the need for additional teaching and demonstration to perform in home. To ensure that infant needs such as feeding, comforting bathing and diapering are met. To determine the need for intervention. To help ensure safe and effective home care. To help ensure the health and well being of the infants which includes absence of infection, adequate nutrition to help. The mothers may be unaware of community resources or services. Praise and positive reinforcement help to build self confidence and assure that the behaviours will be repeated. Family members can offer valuable emotional support to the mother and help with physical care of the infant. Breast feeding ensure the nutritional need of the baby Mother has gained adequate knowledge regarding new born care. She was able to return demonstrate the new born procedures. Performing essential new born care. Assessmen Nursing Diagnosis Objectives t Objective Risk data: fluid volume be from lochia related rubra oral intake thus having and blood risk free and the factors which lead to fluid loss. Expected outcome  Enables to facilitate nursing Normal fluid care. level will be fluid to volume and decrease diuresis Rationale for Mother will  Assess the level of risk for fluid loss The mother deficit has Intervention deficit . maintained.  Monitor hydration status including skin turgor, mucous membranes and subjective feelings of thirst.  Smooth , supple skin, moist mucous membrane absence of thirst and firm eye balls are evidence of good hydration  Monitor intake and output and note the for loss. fluid amount of diaphoresis. volume  To maintain should balance approximately intake equal output. deficit, vital  Measure urine specific gravity as signs and needed. indicates dehydration.  Assess temperature Q4 hourly. intake and  Urine specific gravity in excess output chart  Elevated temperature is a symptoms of dehydration.  Administer and monitor IV infusion as prescribed.  Prevents dehydration and subsequent acidosis for a client who is NPO.  Provide ice chips unless medical order contraindicates them.  Clients may be kept NPO because gastric emptying time is prolonged in labour. Assessment Nursing Objectives Intervention Rationale Expected Objective data: The mother did not know the importance of hygienic measures and does not follow it. Diagnosis Risk for Mother will  Identify the factors that place the mother  Recognition of client risk factors at risk for infection. enhances development of infection be individualized nursing care related to prevented  Monitor vital signs once per shift.  To detect the presence of tissue trauma from infection.  Assess episiotomy site once per shift. from child infection  Redness, swelling increases pain birth and or purulent drainage may indicate the presence of breast infection.  Assess lochia once per shift. complication  Foul smelling lochia is an s. indication of infection.  Assess fundus once per shift.  A uterus that is very tender or remains boggy may indicate retained tissue or uterine infection.  Teach and encourage perineal care several times each day and after voiding  To promote healing and prevent or defecation also teach to change pads infection atleast every 3-4 hours.  Teach to cleanse perineum from front to back.  Prevents the spread of fecal  Teach nipple care like do not use soap , contaminants to the episiotomy. when infant is breast feeding break suction with index finger before  Soap dries the nipples and removing baby from the breast. contributes to cracking. Breaking  Use good hand washing techniques. suction prevents trauma.  Encourage fluid 2000ml/day. intake of up to  To prevent transmission of micro outcome Mother was prevented from infection after following hygienic practice and taking proper diet. organisms.  Assessment Objective Nursing Diagnosis Risk for Mother data: postpartum be prevented Mother has haemorrhage related pain score labour process 5/10, first and atony of the uterus. will from risk of lochia rubra, post natal day, Objectives to post partum Intervention  Identify the risk factors for PPH like long labour, multiparity, large baby, manual removal of adherent placenta, previous history of PPH, excessive uterine manipulation .  Assess fundal height position and tone Q 15mts for Ist hour, then Q30 mints for 1 hour and then hourly.  Monitor lochia for color, amount and presence of clots and odor.  Palpate the bladder. Rationale Expected outcome  Hemorrhage is a common thread Mother was during immediate postpartum period prevented from which leads to fluid volume deficit. post partum     Monitor vital signs.   Institute pad count.   Monitor Hemoglobin and haematocrit level.   Continue IV fluids for 1-2 hours after the birth.  Massage the fundus if boggy. Stop massaging when uterus becomes firm.     Encourage and assist with breast feeding as soon as possible at any time when uterine atony is present. Help increase urine production and prevent urinary stasis To determine the position and firmness of the uterus . fundus should be firm. To identify the presence of abnormal bleeding. A full bladder can displace the fundus and interfere with uterine contraction. Hypotension can occur from hypovolemia secondary to hemorrhage. Excessive bleeding exists if a pad is saturated with in a 15 mts period Aid in estimating the amount of blood loss. To have a ready access for administration of fluids. Massage stimulates uterine contractibility. As the uterine muscles contract, inter bleed vessels are compresses which help control bleeding. Baby’s sucking stimulates the posterior pituitary to release oxytocin which causes uterine contraction. haemorrhage after following hygiene and continuous monitoring of the mother in the post natal period.  Helps to prevent PPH.  Administer oxytocin at birth as per protocol and again during post partum period if uterus doesn’t stay firm. Assessment Nursing Goals Intervention Rationale diagnosis outcome Objective Risk data: impaired breast have effective Mother is not feeding related breast aware to feeding.. of for lack of breast feeding experience due techniques, to feeding pregnancy. interval is first Mother will     feed. Assess the knowledge of breast feeding like position, latching on, assessing sucking and swallowing Assess infant’s maturity level and gestational age.  Observe infant’s ability to suck.   Monitor infants ability to grasp the nipple correctly and latch on.   Assess mother for pain when infant sucks.   Assess for milk let down (tingling sensation in the nipples, uterine cramping, leakage from the opposite breast). Instruct mother on proper positioning and help to position the baby as needed Instruct on proper nipple care, including how to prevent nipple soreness. long, baby is crying Expected for     Teach to feed baby on cue and to not limit the duration of feeding .The baby is finished when the suck/ swallow pattern has slowed, the breast is soft.  Encourage rooming in     To determine the directional needs of Mother the mother to plan teaching. To determine variations that made impede infants ability to suck or latch on to the breast. To determine whether infant is obtaining adequate milk to meet nutritional needs. The ability of the baby to latch on depends on the size of the baby’s mouth and size of the mother’s nipple and areola. May indicate that the infant is not correctly latched on. To ensure that infant is receiving milk. To make mother aware that effective breast feeding depends on proper techniques. Use of soaps and alcohol can dry out nipples, cause cracking and increased pain and soreness. It is incorrect positioning, latching on and removing from the breast that causes sore nipples, not the length of time of feeding lasts.. Provides opportunity for the mother to learn to recognize feeding cues. has gained adequate knowledge regarding breast feeding and practice effective breast feeding techniques.   Before discharge, be sure that the parents are knowledgeable about breast feeding and know when to contact the care provider. Breast feeding does not necessarily come naturally. Breast feeding as a learning process.