FAR EASTERN UNIVERSITY INSTITUTE OF NURSING BATCH 2010

CASE PRESENTATION
BSN048 GROUP 190-B Rieza, Wendy Ann M. Salamat, Neoma Syrilla T. Santos, Janessa Joy S.

Prof. Jeannie Patrimonio

Introduction: The client chosen for this case is R.T.C NORD, female, 26 years of age,. Her religion is Roman Catholic She was born on July 24, 1981 in Tuguegarao City. And married to PO1 T.C PNPSAF B96L28 from Paliparan Dasma, Cavite. Admitted to OBward by admitting officer/ admitting physician PSUPT Guiatani on 21 2330H July 2008, room number 3 with hospital no. 04-01-35. Is Dependent, ambulatory, First type of admission with Direct source of Admission. Has admitting Diagnosis of G2P1 PU 23 4/7 weeks AOG, Pre Term Labor. R.T.C is accompanied by husband with cc of vaginal spotting or verbalized. LmP is February 22, 2008, EDC is November 29, 2008, RR of 21 cycles/min, BP 130/80mmhg with temp of 36.7 and cardiac rate of 78bpm.Conscious and coherent, with negative uterine contraction and positive on vaginal spotting. We chose this case because this case is more challenging among other cases that we’ve handled and there’s a lot to learn from this case. In addition to that, the diagnosis of the patient might be a threat to the fetus that needs to be focused on, assessed for nursing intervention to help prevent further complications. II Nursing History A. Past health History R.T.C 26 y/o G2P1 doesn’t have history on Hypertension, Diabetes mellitus, and asthma. She is diagnosed of hyperthyroidism during her first pregnancy on the year 2006 on PTV but stop after several weeks. B. History of Present Illness

R.T.C was admitted dependent, ambulatory, PU 23 4/7 weeks of AOG, Pre Term Labor. Consulted regarding thyroid problem, still for follow up of FT3 FT4 TSH. Undergone Transabdominal Ultrasound result revealed oligohyramnios (AFI- 1.7cm).

Discharge Plan Medication: Isoxsuprine tablet Q8H Inderal 10mg 1 tab BID MV (natalbes) tablet OD FC Fumirate tab (fumuim) OD Exercise: -CBR Treatment: -rest and sleep -medication -increase fluid intake Health Teaching:

Low levels of amniotic fluid can increase your risk of complications during labor. The main concern is that the fluid level will get so low that your baby's movements or your contractions will compress the umbilical cord. So Oligohydramnios can sometimes be
treated with bed rest, oral and intravenous hydration, antibiotics, steroids, and amnioinfusion. It is advised to continue the increse of oral fluids, have bed rest and consult doctor as advised. Out Patient: -The patient should consult doctor/physician if there are complications after discharge for immediate action.

Start off small. If you're very pregnant. Best Walking Tips While Before you get walking. your shoulders back slightly. eat at regular times and relax while you eat advised a low residue diet. which are loosened by hormones released during pregnancy. Look at the ground a few steps ahead of you — not straight down (which strains your neck and hunches your shoulders) or far off into the distance (in case you have to dodge people or tackle tough terrain). Long ones can hurt your hips and pelvic area. Look ahead. and your elbows bent. Diet: Practice good eating habits. Increase fluid intake to 2liters/day. then pulling it back in so you get a feel for what it means to hold in your abs. learn some easy and sensible tips to make the most of your walk:  Pregnant    Stand tall. as if you're grasping an egg. Just as important as what you eat is the manner in which you eat. A maternity belt has is a wide band that goes under your tummy for support. Begin walking in short strides. Practice relaxing your stomach. Safety: Pregnancy Fitness Safety Tips Staying fit during pregnancy is an important part of feeling your best. Eat moderate proportions. Keep your elbows close to your body. If yours is a low-risk pregnancy. Get into position. Maintain a healthy lifestyle Walking during pregnancy is a great way to feel good and become more fit. and your doctor approves. You can buy one in a maternity store or catalog.-The patient should follow the physicians order. you may want to wear a maternity belt under your clothes for additional abdominal support. Stand up straight and use your abdominal muscles to support your back. Hold your hands in light fists. you can continue to exercise and derive health benefits even from mild-to-moderate fitness .

especially in the first trimester. avoid scuba diving because there's a risk that your oxygen intake could be compromised. Drink up! Drink plenty of water to keep you hydrated and prevent overheating. Be mindful not to become overheated.routines. Keep cool. Wear comfortable. These include activities at high altitudes and those that are associated with a risk of falling or colliding with another participant. you will probably require more. Keep your balance. humid days. Exercising three days a week is a good routine. Avoid exercises that could cause a quick loss of balance or mild trauma to the abdomen. Avoid certain sports. Be sure you eat an adequate diet that allows you to gain 25 to 35 pounds over the nine months. Watch your back. overheating. Avoid activities that require jumping motions or sudden changes in direction because these may strain your joints and injure you. Don't exercise on your back after the first trimester. According to the Mayo Clinic. Be aware that you have less oxygen available for exercise. and diving can put pressure on your organs and baby. Exercise regularly (at least three times a week) — not intermittently. as pregnant women use up this fuel source more quickly during exercise than non-pregnant women. Include plenty of carbohydrates in your diet. Also. Stop exercising when you become fatigued. Drink plenty of fluids before and during exercise. . and don't immerse yourself in a hot tub or sauna. If you exercise regularly. Easy does it. Both actions can reduce blood flow to the uterus. Most pregnant women require an additional 300 calories a day. cool. Don't overexert yourself. and don't exercise to the point of exhaustion. Also. Get comfortable. The American College of Obstetricians and Gynecologists recommends following these guidelines to ensure a healthy pregnancy — for you and your baby. wear layers of "breathable" clothing. and supportive clothing in layers that can be easily removed. According to the American College of Obstetricians and Gynecologists. such as horseback riding. avoid prolonged periods of motionless standing. especially in the first trimester. may be a contributing factor to the development of birth defects. Wear a bra that fits properly and supports your breasts. don't exercise on hot. • • • • • • • • • • Stay consistent. you'll want to avoid certain sports altogether while you're pregnant. Eat a good diet. climbing and snow and water skiing. Keep your fitness regimen in the mild-to-moderate range.

lipids and phospholipids. At 34 weeks ga. . around two weeks after fertilization. The amnion grows and begins to fill. In the late stages of gestation much of the amniotic fluid consists of fetal urine. carbohydrates. mainly with water. This amount reduces to about 600 ml at 40 weeks ga when the baby is born. The amount of amniotic fluid is greatest at about 34 weeks after conception or 34 weeks ga (gestational age). The amniotic fluid increases in volume as the fetus grows.Anatomy and Physiology Amniotic fluid is the nourishing and protecting liquid contained by the amnion of a pregnant woman. the amount of amniotic fluid is about 800 ml. After a further 10 weeks the liquid contains proteins. all which aid in the growth of the fetus. urea and electrolytes.

can reveal many aspects of the baby's genetic health. clubbing of the feet and hands. The majority of the hindwaters remain inside the womb until the baby is born. including brain. These cells have demonstrated the ability to differentiate into a number of different cell-types. and helps protect the fetus from heat loss. and also develop a life threatening condition called hypoplastic lungs. If a baby is born with hypoplastic lungs. allows for easier fetal movement. Amniotic fluid also protects the developing baby by cushioning against blows to the mother's abdomen. Recent research by researchers led by Anthony Atala of Wake Forest University and a team from Harvard University has found that amniotic fluid is also a plentiful source of non-embryonic stem cells. It is important that the fundal height be measured and properly recorded to insure proper fetal growth and the increasing development of amniotic fluid. This is because the fluid also contains fetal cells which can be examined for genetic defects. The forewaters are released when the amnion ruptures. this condition is potentially fatal and the baby can die shortly after birth. In both cases the majority of pregnancies proceed normally and the baby is born healthy but this isn't always the case. which are small underdeveloped lungs. If the rupture precedes labor at term. When this occurs during labor at term. liver and bone. It is essential that the amniotic fluid be breathed into the lungs by the fetus in order for the lungs to develop normally. promotes muscular/skeletal development. Swallowed aminotic fluid contributes to the formation of meconium. it is known as "spontaneous rupture of membranes" (SROM). commonly known as when a woman's "water breaks". however. Complications related to amniotic fluid Too little amniotic fluid (oligohydramnios) or too much (polyhydramnios or hydramnios) can be a cause or an indicator of problems for the mother and baby. as well as being urinated by the baby. Babies with too little amniotic fluid can develop contractures of the limbs.Amniotic fluid is continually being swallowed and "inhaled" and replaced through being "exhaled". The obstetrician/gynaecologist should also routinely ultrasound the . drawn out of the mother's abdomen in an amniocentesis procedure. it is referred to as "premature rupture of membranes" (PROM). Analysis of amniotic fluid. the obstetrician/gynaecologist should measure the patient's fundal height with a tape measure. On every prenatal visit.

COLOR OF AMNIOTIC FLUID WITH CONTRAINDICATIONS GREEN . kidney dysfunction or malformation (since much of the late amniotic fluid volume is urine). steroids. procedures such as chorionic villus sampling (CVS). Polyhydramnios is a predisposing risk factor for cord prolapse and is sometimes a side effect of a macrosomic pregnancy.neco state YELLOW . and amnioinfusion.hemolitic deisease BROWN infection III. antibiotics. Oligohydramnios can be caused by infection.patient—this procedure will also give an indication of proper fetal growth and amniotic fluid development. oral and intravenous hydration. Oligohydramnios can sometimes be treated with bed rest. Hydramnios is associated with esophageal atresia. Amniotic fluid is primarily produced by the mother until 16 weeks of gestation. Activities of daily living Activities of Daily Living Before Hospitalization During Hospitalization Analysis & Interpretation . and preterm premature rupture of membranes (PPROM).

or 30 ml/kg of body weight.” “ Madami akong uminom ng tubig ngayon kasi yun ang inadvice sa’kin. vitamins. lalo na mga gulay.” She doesn’t have any problems regarding her nutritional intake.” “ Minsan ayoko ng binibigay nilang ulam kaya nagpapabili ako sa labas. Nutrition is vital aspect of the health of women at all ages and is particularly important during the childbearing years because it affects the health and development of the child.” “ Hindi ako masyadong umiinom ng tubig dati. karne. fats. carbohydrates. and minerals. Madalas sabaw. An adequate food intake consists of a balance of essential nutrients: water. Madalas akong kumain ng meat. Nutrition during pregnancy has implications for both the mother and the fetus. atay. The pregnant woman needs an additional daily 30 ml of water per kilogram of body weight gained. proteins.NUTRITION The client verbalized: “ Nakakain ko gusto ko. with a minimum of 6 cups (1500 ml) for small individuals. . Because the pregnant woman’s blood volume is expanding water and other fluids should be increased. at gulay pero hindi na ako mayadong kumakai ng isda ngayon kasi ayoko yung amoy. The usual recommendations for adults are to drink 8-10 cups (1 cup=8oz=237 ml) of water per day. She increased her oral fluid intake to improve her condition being diagnosed with oligohydramnios. The mother’s nutrition before pregnancy is also important for the health of the fetus. Mas madami pa sa 2 liters naiinom ko sa isang araw. mga 1 liter lang.

There is an increased urine flow and volume as well as bowel movement for pregnant women because of their increased fluid intake and nutritious foods intake and the supplements they needed. The client is not capable of rigid exercises because of her condition.kadalasan ay sampung beses o di kaya 15. The benefits of exercise on these system follows: Musculoskeletal.” “Dalawang beses dn akong dumumi ditto sa isang araw. Regular exercise is essential for healthy functioning of major body systems. tone & strength of muscles are maintain with mild exercise and increases with strenuous exercises. Elimination of the waste products of digestion from the body is essential to health.size. umiihi ako sa isang araw. She is only allowed to have a complete bed rest.minsan” “kadalasan nakaupo at nakahiga lang ako dito.” “Madalas ako umihi kapag napaparami inom ko. Cardiovascular.ELIMINATION “Nakakadalawang beses akong dumumi sa isang araw. Respiratory.increase heart rate.” The patient’s bowel movement is normal and there is an increase in her urinary elimination but it is still normal because there is an increase in her fluid intake.” . Exercise to stay regular like walking three to four times per week for 2030 minutes is recommended.” “Bawat oras. shape. EXERCISE “hindi ako nageexercise pero naglalakad naman ako paminsan.ventilation increases.

” “3 beses magtoothbrush” “lagi kong pinananatiling malinis katawan ko. Excessive. puro pagpupunas lang dati. chronic ingestion of alcohol can impair nutrition.produce a sense of well-being and improes tolerance to stress. “wala akong bisyo” The patient doesn’t take any drugs or substances that may affect her health and the fetus inside her. Urinary.” “wala akong bsyo.HYGIENE SUBSTANCE USE “dalawang beses sa isang araw akong maligo. Psychoneuologic. facilitating peristalsis. The patient was not allowed to take a bath before that’s why she didn’t meet the standards regarding her hygiene particularly in taking a bath.improves the appetite and increase gastrointestinal tract tone. Newborn born to mothers who .promote efficient blood flow.” Gastrointestinal.elevates metabolic rate. It may also affect the health and development of the growing fetus inside her womb. Women who are pregnant should abstain from consuming alcohol.” “tatlong beses pa rin ako nagsisiplyo. Metabolic. body excretes waste more effectively.” “ngayon lang lit ako nakaligo. masama para sa baby ko. Excessive alcohol intake may limit the necessary intake of calories and nutrients.

” “sa hapon nagpapahinga din ako ng mga isang oras.no body odor 37۫ C 82 bpm 20 bpm Analysis NORMAL Temperature Pulse Rate Respiratory Rate NORMAL NORMAL NORMAL . erect posture. Rest and Sleep are essential for health. a higher incidence of SIDS.SLEEP & REST “mga anim na oras tulog ko dati. Large doses of illicit drugs or street drugs can cause low birth weight or fetal distress. sitting on bed -conscious..6 F) 80 bpm (60-100 bpm) 16 bpm (12 -20 bpm) Actual Findings -the client wears a clean clothes. coordinated movement Clean. coherent . Physical Assessment Body Parts General Appearance Normal Findings Varies with lifestyle Relaxed.” smoke have lower birth weights. IV. The client has an irregular sleeping pattern and does not meet the normal range of sleeping hours for pregnant women. People who are ill frequently require more rest and sleep than usual same with those pregnant women who needs more rest. a higher incidence of premature birth and are more likely to have episodes of apnea. pero kadalasan limang oras tulog ko. Neat No body odor Healthy appearance 37۫ C (98.” “Minsan napuputol pagtulog ko.

-can be black. nits and dandruff -maybe thick or thin. brown. quality and organization of speech is understandable. abrasions. exhibits thought association -thoughts are in logical sequence. resilient hair -no infections or infestation -color varies from light to deep brown -no edema. -Cooperative -Client’s response appropriate to situation -Quantity. makes sense and has sense of reality. cyanosis and lesions -moisture in skin folds and axillae -good skin turgor -Sits in erect posture -active -the patient was able to answer well -has an organized thoughts -she is cooperative NORMAL Mental Status: Verbal Behavior NORMAL Hair -black color of hair -her hair is evenly distributed -smooth in texture NORMAL Skin Color: slightly dark skin Feel: warm to touch Turgor: good skin turgor -there is a presence of edema There is a presence of edema because of the IV insertions. or burgundy in color. . pallor. evenly distributed -silky.Posture Erect posture and an active purposeful stride suggest a feeling of wellbeing. moderate pace. free from lice.

Folart (folic acid) 1 tab.V. 2008 with the BP of 130/80. 22 2100H July 2008. Undergone CBC and UA results were normal.T.T. Monitor V/S every shift. intramural myoma nodule upper anterior (3. D5NM 1L X 6hours. Continue duvadilan drip and increase OF 2L/day. D5LR IL X . Natalbes 1tab OD. Dx asymptomatic FT3 FT4 FST (047/2008) normal.0cm) with note of multicystic left kidney.5x2. 25 0700H July 2008. calcium 1tab q’12.C undergone transvaginal ultrasound.7’C and 23 4/7 weeks AOG. Advised increase of Oral Fluids to 2L/day. Femiron 1tab OD.C was admitted to Ob ward on July 21. Undergone transabdominal ultrasound at 24 1500H July 2008 for amniotic fluis quantification resulted oligohydramnios. Given IVF of D5 W 1L +8amps duvadilan to run for 15ugtts/min after checking BP and CR. Course in the Ward R. IVF to follow are D5LR 1L fast drip 300cc then regulate to 6 hrs. Given the medicine Ampicillin 1g IV q’6 ANST. R. suggested congenital anomaly scan at 24 weeks AOG by physician. temperature of 36. Diet is DAT.

1100H permitted to take a bath. still increase of fuid intake and to continue IV series D5LR5 1L x 6 hours. To discontinue ampicillin IV and duvadillan drip to consume and then shift to duvadilan tablet BID.27-4. 2008) or on next ultrasound. Advised to maintain in lateral derubitus position. D5NR IL x 6 hours. Vital sign ans FHT monitored and recorded. PRwas Immunology FT3 (ECLIA) FT4(ECLIA) TSH(ECLIA) Result 3.710 13.20 Analysis? 82. 20 July 2008 undergone transvaginal ultrasound at AGRA. 30 1930 July 2008 for congenital scanning @ 28 weeks (august 12. D5NM 1L x 6 hours. Monitored V/s FHT and recorded. D5NM IL x 6 hours.80-7. Laboratory and Diagnostic Examinations Result . Last Bp taken 110/70 temperature is 37’C RR-20.C is advised on a low residue diet.T. pt may turn on Lest and right. R.370 Unit Pmol/L Pmol/L uIU/ml Referenceranges 2.6hours. 26 0725H July 2008.59 2.10 12-22 0.

count Neutrophils Pt Value 9.0 0.65 .025 Negative Negative 0-1hpf 0-2/hpf Hematology 04/30/08 Leukocyte count Leukocyte diff.35-0. amber clear Acidic 1.Urinalysis Result 07/21/08 Macroscopic exam Color Transparency Reaction Specific gravity Sugar Protein Microscpic exam RBC Pus Cell Squamous Ephitilial cells result straw S.5-11.I turbid Acidic 1.8 x10 9/L 0.005 Negative Negative 0-2 0-2 few Norm Straw.005-1.67 Reference range 4.

Eosinophils Lymphocytes Hemoglobin hematocrit 0.7cm) Placental grade: grade 1 Pregnancy Uterine.05 0.40 120-160 0. Ultrasound 2 Obstetrics Ultrasound Report 7/28/2008 . frac 0.30 110g/l 0.5 x 2.20-0. upper anterior (3.41 Ultrasound 1 Obstetrics Ultrasound Report 24 July 2008 Second and third trimester ultrasound report Final impression: Cephalic presentation.36 vol.00-0.03 0.0) With note of multicystic left kidney Suggest congental anomaly scan at 24 weeks AOG. live singleton No previa Posterior placenta location] Amniotic fluid volume: oligohydramnios (AFI=1. 21 wks 3 days AOG by fetal biometry Intramural myoma nodule.37-0.

8 Q2.192mm 21weeks 3days AC .163mm 21weeks 1day FL .52mm 21weeks 4days HC .. but generally scanning showed still with oligohydramnios . 429 grams Remarks: The amniotic Fluid index has improved slightly.1 Placenta location: fundus Fetal Biometry BPD .2.35mm 22weeks 1day AV Sonar age 21 weeks 4 days Estimated date of delivery: 12/04 Wstimated fetal weight.2nd and 3rd trimester Number of fetus: 1 Presentation: breech Amniotic fluid volume: 39 (2vp) Q1.1.

Generic Name Dosage/ Frequency Classificatio n Indications Contraindicat ions Side effects Nursing Consideratio ns .

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Intervention decrease distraction and promote learning. 3. efficient . Provide written information on oligohydramnios about its causes. Through this interventions the client was been able to verbalize understandin g of individual factors that contribute to possibility of fetal injury and take steps to correct her situation 1. To enhance . Analysis At risk of fetal injury as a result of environmen tal conditions interacting with the individual’s adaptive and defensive resources Planning Goal: After 4 hrs of nursing intervention. effective and adequate for the clients condition. Accurate info encourages compliance and written resources for later review and self paced 4. Verbalize complication and effect of oligohydramnios to the baby 2. family may reinforce teaching and help client comply 2 . Assess clients ability to understand teaching 1. Assessment provide info to guide planning an individualized teaching program to ensure the clients understanding 2. the client will verbalize understanding of individual factors that contribute to possibility of fetal injury and take steps to correct situation Objective: After 4 hrs of nursing intervention. Abide to the doctors order and health teachings. Provide information on 3. Provide a comfortable quite setting for teaching and invite family to participate 3. effect and complication 4. the client will: 1 .Cues OTransabdomin al Ultrasound resulting in Oligohydramni os Nursing Diagnosis Risk for Fetal Injury related to cord compression secondary to decreased amniotic fluid as manifested bu Trans abdominal ultrasound result. Verbalize the definition and possible causes of oligohydramnios Intervention Rationale Evaluation All the Nursing intervention rendered to the client were appropriate.

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Some clients may believe that preterm infants have few problems or that 7 month babies do better than 8 month gestations(old wives tale) 2. Describe steps to take to avoid preterm labor 2. Assist clients understanding of the risks of preterm labor and birth for her baby. Assessment provide to guide planning an individualized teaching program to ensure client understanding. Yun lang ang alam ko” as stated by the client -“ Hindi naman ako naghihilab. 4. effective and adequate for the clients condition. Describe signs and symptom of preterm labor 2. Help client to identify Braxton- 4. Assisting empower the client to recognize . the client will: 1. 1.Cues Nursing Diagnosis Deficient Knowledge regarding Preterm labor prevention related to unfamiliarity with preterm labor Analysis Planning Goal: After 4 hrs of nursing intervention. 3. the client will verbalize increase knowledge about preterm labor Objective: After 4 hrs of nursing intervention. 2. Interventions decrease distractions and promote learning.gu magalaw lang yung baby sa tiyan ko” as stated by the client O.“ Ang alam ko lang pwede malaglagan ng bata pag ganun eh” as stated by the client -“Sabi nila pwede daw akong manganak ng wala sa kabuwanan pag ganun.less anxiety Absence or Deficiency of cognitive information related to specific topic (preterm labor prevention) 1 . Intervention Rationale Evaluation All the Nursing intervention rendered to the client were appropriate. family may reinforce teaching and help client comply. Through this interventions the client was able to verbalize understandin g about s/s of preterm labor and what’s its possible prevention S. Provide a comfortable quite setting for teaching and invite family to participate in session 3. efficient . Assess client’s risk factor for preterm labor and ability to understand teaching 1.

Cues Nursing Diagnosis Analysis Planning Intervention Rationale Evaluation .

problem of mobility. Interventions decrease distractions and promote learning. Provide for physical as well as mental diversional activities . or sensory deprivation may onterfere with desired activity 3. the client will: 1. Be motivated and stimulate client involvement in solution 2.doctors order to have complete bed rest with out bathroom privileges Deficient Diversional Activity related to prescribed complete bed rest without bathroom privileges secondary to preterm labor Decreased stimulation from recreational or leisure activities. Promote wellness 1 . Goal: After 4 hrs of nursing intervention. Presence of depression. the client will verbalize examples of satisfying activities within personal limits Objective: After 4 hrs of nursing intervention. family may reinforce teaching and help client All the Nursing intervention rendered to the client were appropriate.O. effective and adequate for the clients condition.Determine ability to participate in activities that are available 2.Acknowledge reality of situation and feelings of the client 1. protective isolation. Through this interventions the client was able to verbalize understandin g about s/s of preterm labor and what’s its possible prevention 3. 1. efficient .

service 6. Many women are unaware that Braxton-Hicks are contraction even if they are not painful 6. hobby clubs.g.comply. Teaching promotes self care and . 4.) 4. encourage mix of desired activity( e.Some clients may believe that preterm infants have few problems or that 7 month babies do better than 8 month gestations(old wives tale) 5. reading. music. Assisting empower the client to recognize mild uterine contraction. Make appropriate referrals to available support groups. Accept hostile expressions while limiting aggressive acting-out behavior 5.. news program etc.

Client may not experience contractions as . 6. The fundus is the thickest part of the uterus where contractions are most easily felt. Teaching empowers client to recognize subtle signs of preterm labor. Teaching promotes awareness of sensations of contractions and fetal movement. 7.organizations assessment skills. Journal provides a written record of activity.

Instruction avoids activity that may cause the release of oxytocin from posterior pituitary gland. Instruction allows client to have some evaluation of preterm labor . Semen contains prostaglandins that may affect uterine activity. 8. Dehydration or a distended bladder may increase uterine irritability/activit y.such. 9. 10.

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Deficient Knowledge regarding Preterm labor prevention related to unfamiliarity with preterm labor Deficient Diversional Activity related to prescribed complete bed rest without bathroom privileges secondary to preterm labor Rank 1 Justification It is a life threatening situation that needs immediate interventions. 2 It does not need immediate interventions because our nursing intervention is only to provide information about preterm labor. This nursing Dx is least addressed because it focuses on psychomotor and it is not that life threatening.Prioritization: Nursing Diagnosis Risk for Fetal Injury related to cord compression secondary to decreased amniotic fluid as manifested bu Trans abdominal ultrasound result. 3 .

Environment too little amniotic fluid . the host which is the fetus. Hypothesis Based on the gathered data and information. a factor (biologic. Lastly. chemical. Predisposing Factors We chose Agent-HostEnvironment Model since according to her diagnosis. Environment This model is composed of Host nt three dynamic. the agent will be the mother. mechanical. we presume that the fetus is the host. The Agent. the mother is the agent and the amniotic fluid is the environment. Agent . We know that when a single component of this model will be altered. interactive st elements.ECOLOGIC MODEL A. Second. wherein everything external to the host that makes illness more or less likely which is the amniotic fluid. The mother acquired oligohydramnios because of certain factors such as decrease fluid intake (1 liter/day) B. a living being capable of being infected or affected by the agent. the environment. physical. In this case. psychosocial) that must be present or absent for an illness to occur. a disease or illness will take place.

we advise the client to continue her ongoing treatment for the promotion of her wellness and her baby’s wellness and reduce further complication. Failure of fetal kidney development Blocked urinary excretion Decrease in fetal urine production . she has inadequate gluid intake before admission to the hospital. Conclusion and Recommendation After analyzing the client’s predisposing factors that affect her condition. As stated by the client. As for the recommendation.C. PATHOPHYSIOLOGY (Can be associated) Fetal abnormalities (growth restricted fetuses) Redistribute blood flow away from their kidneys. we conclude that the agent is the primary factor that causes her to acquire her present condition.

malformations may result to compression of fetal parts. fetal death .Decrease in amniotic fluid volume (oligohydramnios) Contractions occur or movements of the fetus in the womb Compression of the umbilical cord Poor fetal lung development (pulmonary hypoplasia).

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