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  • This Study Resource Was Shared Via: Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation

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    Danica Fave Andiam
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    The document summarizes the nursing care plan for a patient who presented with a risk of maternal infection due to prolonged ruptured membranes. The nursing diagnoses identifies the risk for maternal infection. The objectives are for the client to be free of signs of infection after nursing interventions. Interventions include monitoring vital signs and white blood cell count, performing vaginal exams with aseptic technique, and providing fluids and perineal care. The rationale explains how the interventions help prevent infection by limiting contaminants and bacterial growth. The evaluation confirms the client was free of infection signs after nursing care.

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    1st_Stage_of_Labor__NCP_.docx

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    The document summarizes the nursing care plan for a patient who presented with a risk of maternal infection due to prolonged ruptured membranes. The nursing diagnoses identifies the risk for maternal infection. The objectives are for the client to be free of signs of infection after nursing interventions. Interventions include monitoring vital signs and white blood cell count, performing vaginal exams with aseptic technique, and providing fluids and perineal care. The rationale explains how the interventions help prevent infection by limiting contaminants and bacterial growth. The evaluation confirms the client was free of infection signs after nursing care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    11 views3 pages

    This Study Resource Was Shared Via: Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation

    Uploaded by

    Danica Fave Andiam
    The document summarizes the nursing care plan for a patient who presented with a risk of maternal infection due to prolonged ruptured membranes. The nursing diagnoses identifies the risk for maternal infection. The objectives are for the client to be free of signs of infection after nursing interventions. Interventions include monitoring vital signs and white blood cell count, performing vaginal exams with aseptic technique, and providing fluids and perineal care. The rationale explains how the interventions help prevent infection by limiting contaminants and bacterial growth. The evaluation confirms the client was free of infection signs after nursing care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 3

    CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

    SUBJECTIVE: Risk for maternal infection related At the end of nursing  The incidence of At the end of nursing
    “Kanina pa po pumutok to prolonged ruptured amniotic interventions, the client will  Monitor vital signs, and chorioamnionitis (intra- interventions, the client
    panubigan ko” as verbalized by membrane. be free of signs of infection white blood cell (WBC) count, amniotic infection) was free from signs of
    the patient. (e.g., afebrile; amniotic fluid as indicated. increases within 4 hours infection (e.g., afebrile;
    clear, nearly colorless and after rupture of amniotic fluid clear, nearly
    odorless). membranes, as evidenced colorless and odorless).
     Perform initial vaginal

    a
    by elevations of WBC count
    examination; repeat only

    vi
    and abnormal vital signs.
    during contractile pattern or
    OBJECTIVE: client’s behavior indicates  Frequent vaginal

    d
    significant progress of labor. examinations can lead to

    e
    Restlessness the incidence of ascending

    ar
    Irritability  Use aseptic technique during tract infections.
    Facial grimace a vaginal examination.

    sh
    Discolored amniotic sac  Helps prevent the growth
    of bacteria; limits
     Demonstrate good hand
    contaminants from

    as
    Vital Signs: washing techniques. reaching the vagina.
     BP – 124/80

    w
     T – 37.7 °C  Assess vaginal secretions  Reduces risk of
     HR – 110 using phenaphthazine acquiring/spreading

    m e (nitrazine paper). Perform infective agents.


    co rc
    microscopic examination for
    positive ferning.  Spontaneous rupture of
    o. ou
    membranes 1 hr or more
    before the onset of labor
     Monitor and describe the
    increases the risk of
    er res

    character of amniotic fluid. chorioamnionitis during


    the intrapartal period.
     Provide oral and parenteral Color changes of nitrazine
    dy
    stu

    This study source was downloaded by 100000781299023 from CourseHero.com on 12-04-2021 01:18:33 GMT -06:00
    fluids, as indicated. paper from yellow to dark
    blue indicate presence of
     Encourage perineal care after alkaline amniotic fluid;
    ferning indicates rupture of
    elimination and prn as
    membranes. Note: Excess
    indicated; change underpad/
    bloody show, which is
    linen when wet. more alkaline than vaginal
    secretions, may cause
     Carry out perineal similar changes on
    preparation, as appropriate. nitrazine paper.

    a
     Obtain blood cultures if  The amniotic fluid during

    vi
    symptoms of sepsis are an infection becomes
    thicker and yellow-tinged
    present.

    d
    and has a foul-smelling
    odor.

    e
    ar
     Administer cleansing enema,  Maintains hydration and a
    if indicated. general sense of well-

    sh
     Administer prophylactic being.
    antibiotic IV, if indicated.
     Reduces risk of ascending

    as
     Administer oxytocin infusion, tract infection.

    w
    as ordered.
     Some providers believe it
    may facilitate perineal

    m e repair at delivery and


    co rc
    cleaning of the perineum in
    the postpartal period,
    o. ou
    thereby reducing the risk
    of infection.
    er res

     Detects and identifies


    causative organism(s).
    dy
    stu

    This study source was downloaded by 100000781299023 from CourseHero.com on 12-04-2021 01:18:33 GMT -06:00
     Although not often done,
    bowel evacuation may
    promote progression of
    labor and reduce risk of
    infection caused by
    contamination of the
    sterile field during delivery.

     Although antibiotic
    administration during the

    a
    intrapartal period is

    vi
    controversial because of
    antibiotic load for the

    d
    fetus, it may help protect
    against development of

    e
     chorioamnionitis in the

    ar
    client at risk.

    sh
     If labor does not happen
    within 24 hr after rupture
    of membranes, an infection

    as
    may occur. If client is at 36
    weeks’ gestation, onset of

    w
    labor reduces risk of
    negative effects on

    m e client/fetus.
    co rc
    o. ou
    er res
    dy
    stu

    This study source was downloaded by 100000781299023 from CourseHero.com on 12-04-2021 01:18:33 GMT -06:00
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