CASE SCENARIO CONCEPT MAP
Legend Profile :
Name: Nancy Age: 26 years Old
Profile Sex: Female Civil Status: Married
Blood type: O+ Review of Anatomy and Nursing Diagnosis Nursing Care Plan
Physical Assessment Physiology
Room No.: Ward A
Review of Anatomy and Physiology Date ofAdmission: January 25, 2021
Chief Complaints: Ruptured membranes
Nursing Diagnosis o Desired Nursing Interventions: Rationale:
Nursing Diagnosis: Anxiety r/t Fear Outcomes:
for the well being of mother and fetus 1. Provide reassurance and support; Evaluation:
Objective Nervous System acknowledge anxiety and use touch, speak 1. These measures communicate care and concern
secondary to situational crisis as After 1 hour of for the woman. They also prevent transmission of
slowly, and remain calm. After 1hour of rendering nursing care, the client has
rendering nursing anxiety from the nurse to the woman/couple
Nursing Intervention and Rationale Sights and sound which are the evidenced by increased apprehension care, the client will be been relieved from her anxiety as evidenced by :
relieved from anxiety 2. Urge the part/support person to remain with
stimuli are processed first by the 2. Presence provides continuing emotional support if
Physical Assessment as evidenced by: the woman as much as possible
this is culturally acceptable and agreed to by the
1. Patient looks relaxed and active.
Objective data:
Rationale General Survey: thalamus and send a signal to the anesthesia care provider.
- Poor eye contact 1. Appear relaxed and 3. Maintain eye contact during preoperative
amygdala or to the cortex. procedures 2. Recognition and effective verbalization of anxiety of
- Increased wariness report anxiety is reduced 3. The presence of caregivers wearing masks may
Evauluation Mood:Uneasy, anxious, and irritable Amygdala is the emotional core of - Fidgeting to a manageable level. be anxiety producing. Eye contact, when possible,
the mother.
4. Include the woman/partner in
the brain and its primary role is to - Maternal vital signs: discussion/conversation in the operating
provides support.
3. Performed breathing techniques and relaxation
2. Verbalized awareness of
Mental state: awake, conscious, and trigger fear response. Locus BP:110/90 Maternal Pulse rate: 86 feelings of anxiety. room
4. Ignoring the woman is depersonalizing and
exercises
5. Encourage use/continuation of breathing
oriented to time, place and people ceruleus receives the signals from beats/minute Temp: 37oC techniques and relaxation exercises.
increases anxiety.
SUBMITTED TO: 4. Support person actively participates in the
the amygdala and it is responsible Subjective data: 3. Identify healthy ways to discussion and provides emotional support for the
ASST. PROF, BARBARA LYN A. GALVEZ 5.Helps to reduce anxiety and enables client to
Gait: body movements are well for initiating many of the classic - Verbalized, ?Nurse nibuto na akong deal with and express 6. Provide opportunities for client input into
participate actively.
birthing mother
coordinated anxiety responses; rapid heart tumatob, ma okay rami sa akong bata anxiety. decision-making process
SUBMITTED BY: 6. Enhances client?s sense of control even
beat, increased BP, sweating, ani??
BANAGUDO, JULIA Abdomen: though much of what is happening may be
fidgeting and pupil dilation. - Verbalized, ?Nurse nabalaka ko paras 4. Use resources/support
beyond her control.
CAJES, DIOSDADO III O a.Shape: egg shape -this shape usually systems effectively
akong bata ug akong kaugalingon kay
ESTOQUIA, ZARAH THEA C indicates that the baby is presenting pinakauna paman gd nako wala ko
MALAYO, ANN JEANNITH C ?head-down?
kabalo unsay buhaton?
b.Scar: No presence of scar.
Fundal Height: 37 cm
Cervical Dilation: 7 cm
Maternal- Fetal Circulation
Rationale:
Contraction: Every 3-5 mins that last long Nursing Diagnosis: Risk for impaired
During pregnancy, the fetal circulatory
for 45-60 seconds; strong and long gas exchange r/t cord compression as Desired Outcomes: 1. Detects severity of hypoxia and possible
system works differently than after evidenced by low fetal heart rate. cause. The fetus is vulnerable to potential injury
Nursing Intervention
Amniotic Fluid: Fluid is clear and birth: After 1 hour of rendering 1. Assess FHR changes during a during labor, owing to situations that reduce Evaluation:
odorless The fetus is connected by the nursing care, the fetal baby contraction, noting decelerations and oxygen levels, such as cord prolapse, prolonged
Objective data: and birthing mother will head compression, or uteroplacental After 1 hour of rendering nursing care, the fetal baby
umbilical cord to the placenta. accelerations.
- Maternal vital signs: remain free from impaired insufficiency. and birthing mother remain free from impaired gas
Vital signs: (Mother) Through the blood vessels in the BP:110/90 gas exchange as exchange as evidenced by:
2.Note and record color, amount, and
BP:110/90 umbilical cord, the fetus gets all Maternal evidenced by:
odor of amniotic fluid and time of
1. Will display FHR 2. In a vertex presentation, prolonged hypoxia
Maternal Pulse rate: 86 beats/minute needed nutrition and oxygen. The Pulse rate: 86 beats/minutes membrane rupture. results in meconium-stained amniotic fluid
and beat-to-beat 1. Displayed an FHR of 135 BPM with no abnormal
Temp: 37oC fetus gets life support from the mother Temp: 37oC variability within normal owing to vagal stimulation, which relaxes the beat-to beat
through the placenta. Waste products 3.Monitor maternal heart rate and blood fetal anal sphincter. Hydramnios may be
- Fetal vital signs: limits. 2. Variability
pressure every hour and as needed or associated with fetal anomalies
Vital signs: (Fetus) and carbon dioxide from the fetus are FHR: 100 bpm 2. Will be free of
per hospital protocols or physician's
adverse effects of 3. Amniotic fluid presents no color, no unusual odor,
FHR: 100 sent back through the umbilical cord - Umbilical cord compression diagnosed by order and within normal amount.
hypoxia during labor 3. Decreased cardiac output or maternal
and placenta to the mother's means of ultrasound hypotension can result in decreased blood flow
The mother is feeling anxious and circulation to be removed. 4. Reposition the client 4. Maternal vital signs: BP: 120/ 80
3. Maternal vital signs to the placenta
5. HR: 78
worried for her baby and herself when Subjective data: are within normal values
5. If non reassuring patterns occur, 6. Temperature: 37 degrees celsius
her amniotic sac ruptured. Umbilical cord. - Mother verbalizes ?Wala na kaayo ko kabati provide 8-10 L/min by mask 4. Changing positions to the side or knee-chest
4. Absence of
Umbilical cord contains 2 arteries and sa paglihok sa ako anak? nonreassuring FHR
can relieve pressure on the umbilical 7. There is no sign of late decelerations, severe
6. Notify the health care provider of cord,allowing more blood to flow through it. variable, and absent variability in the FHR
a vein. Itcarries oxygen and nutrients patterns (late Repositioning also prevents supine
nonreassuring FHR patterns
to the fetus and waste products away decelerations, severe hypotension, which decreases blood flow to the
from the fetus. variable, absent placenta.
variability, etc)
Placenta 5.Oxytocin intensifies uterine contraction, which
The fetus takes in oxygen, nutrients, decreases placental blood flow.
and other substances from the
6.Allows additional uterine contraction, which
placenta and gets rid of carbon decreases placental blood flow.
dioxide and other wastes.
