Aliza Grace F.

Savarez
NCP in Polyhydramnios
Name: L,M

Room and Bed Number: 338-1

AP: Dr. Tuazon

G4 P3 A0 T3 P0 A0 L2

Chief Complaint: Labor Pains

Diagnosis: polyhydramious

Date /
time
Dec.
10,
2014
9:00
am

Cues

Need

Objective:
Pregnant
women of AOG:
37 weeks and 6
days
G4 P3 A0

ActivityExercise
Pattern

35 | P a g e

Diagnosis:
polyhydramnios

Ultrasound
result of cleft
palate fetus.

Changes in
fetal heart tone
with Fetal
bradycardia
with
deceleration
during
contraction

Nursing
Diagnosis
Impaired gas
exchange( feta
l ) related to
interruption of
blood flow
from placenta
and fetus as
manifested by
fetal congenital
abnormality
(cleft lip and
palate )

( Nurses
Pocket
Guide, 2010)

Goal of care
After series of
nursing
intervention
Within 30 to 1
hour of nursing
care, the patient
will:
Intented
outcome:
To have a better
outcome of the
pressure from
the presenting
part by removing
or alleviating the
pressure to
improve fetal
perfusion.

Nursing Intervention

1. Monitor maternal
vital signs
2. Monitor fetal
heart rate
frequently, By
obtaining
electrical fetal
monitoring
tracing.
R: to obtain the
result if it is
abnormal or not and
to report the
changes
immediately.
3. Change
maternal
position usually
the best position
is knee-chest
position. A

Evaluation

Dec. 10, 2014

11:00 am
Goal met
After series of
nursing intervention
Within 30 to 1 hour
of nursing care,in
our 8 hours of duty
the patient was able
to:
a. Obtains a
fetal heart
tone of :

11: 00 am

8:31 am = 118 bpm

9:30 am = 140 bpm
10:30 am = 120 bpm
Normal range (120
160 bpm )

Excessive
amount of
amniotic fluid in
the uterus

AFI of
24.9 cm
(Normal range from
500 to 1,000 ml and
2,000 ml in
polyhydramnios at 40
weeks gestation. And
an AFI of 24-25 cm )

36 | P a g e

a. The fetal
heart rate
will be in
a
consisten
t normal
range
with no
decelerat
ions
b. Maintain
the
safety of
both
mother
and the
child.

Trendelenburg
position or sims
lateral positon
R: to relieve the
pressure of the
presenting part so
that the oxygen can
get through the
baby.
4. Inform the client
to report
immediately if
she feels the
cord within the
vagina
R: to give action
immediately and
to prevent any
danger risks.

138 to 148 bpm

(Normal range 120

160 bpm )
Consistently.

b. And the
safety of the
mother and
the child is
maintained. (
there are no
signs of
prolapse of
the cord )

Aliza Grace F.Savarez St.N