A Nursing Care Plan on

OLIGOHYDRAMNIOS

In Partial Fulfillment of the Requirements in NCM 207 – RLE

DELIVERY ROOM ROTATION

Submitted To:
MS. TRINA DOMINAIS, RN, MAN
Clinical Instructor

Submitted By:
MELANIE G. CABRIADAS ST, N.
BSN 2R – GROUP 2

December 1, 2022
GORDON’S FUNCTIONAL GATHERED DATA PRIORITY
HEALTH PATTERN

➢ Negative RT – PCR Test

Health Perception / Health
Management
➢ Fully Vaccinated (Pfizer) w/o booster
➢ Present hyperthyroidism (diagnosed since 16 yrs.
old) HIGH
➢ Takes PTU (Propylthiouracil) for hyperthyroidism
➢ Present for oligohydramnios
➢ In Preterm Labor
➢ Allergic to Co-amoxiclav

PAST HEALTH HISTORY

➢ Had UTI at 30 weeks of gestation; water therapy
➢ Placenta Previa @20 weeks AOG
Initial VS:
➢ CR: 70 bpm
➢ PR: 69 bpm MEDIUM
➢ RR: 21 cpm
➢ Temp: 36.5
➢ BP: 110/90 mmHg
Latest VS:
➢ CR: 71 bpm
Nutritional-Metabolic ➢ PR: 65 bpm
➢ RR: 22 cpm
➢ Temp: 36.5
➢ BP: 110/90 mmHg
Intake
➢ Eats 1 burger for snack
➢ 1 cup of rice, 1 piece of chicken, 1 piece of fish, a
bowl of soup, and 1 banana
➢ Administered half a dose of Primigyn 0.5 mg
➢ Administered PLR 1L @120 cc/hr

Elimination
Activity – Exercise
Cognitive – Perceptual
Sleep – Rest
Self – Perception / Self – Concept
Role – Relationship
Sexuality – Reproductive
Coping/Stress Tolerance
Values/Belief
➢ No problem with urinary and bowel control
➢ Urine – 5x
➢ Stool – 1x LOW
➢ Used suppository (laxatives) – Dulcolax
➢ Was prescribed to walk as doctor’s order
➢ Slow paced walk evident
➢ Oriented
➢ Inefficient sleeping time due to labor pain
➢ Maintains good eye contact, good attention span
and is also assertive.
➢ A wife and also married
➢ Former teacher for 4 years.
➢ Worked at PRC
➢ Sexually active
➢ Gravida 1
➢ Last menstrual period: March 12, 2022
➢ Emotional support in talking things over – Husband
➢ Perform Deep Breathing Technique
➢ Socially interact with the health care team member
• Roman Catholic
 Nursing Care Plan
Name of Patient:
Chief of Complaint: Labor Pain Age: 32 years old Sex: Female Room #: 307 Bed #: 4
Diagnosis: Hyperthyroidism & Olygohydramnios Attending Physician: Dr. Torres

Date & Time Cues Need Nursing Diagnosis Patient Outcome Nursing Intervention Implementation Evaluation
Subjective: H Risk for Maternal – Within 8 hours of 1. Establish Rapport with the 1 November 26, 2022
N Fetal Dyad related to nursing intervention, patient.
E
O • Frequent Maternal Comorbidities the patient will be able @11:00 pm
Urination A (e.g.) Hyperthyroidism to: R: To obtain
V • Abdominal Pain as evidenced by cooperation and “Goal Partially Met”
L
E • Painful uterine decreased amniotic fluid a. Participate in participation.
contractions. T (oligohydramnios) Screening Within 8 hours of giving
M procedures as 2. Assess the gestational age, 2 continuous nursing care
H
indicated. maternal factors like intervention, the patient
B
Rationale: hyperthyroidism, fundal will be able to:
E Oligohydramnios is b. Engage in height, and monitor fetal
P
associated with necessary movements & fetal heart a. Cooperate in
R
Objective: E increased perinatal alteration in rate. various screening
morbidity and mortality. lifestyle and procedures for the
R
2 • Diagnosed It may be due to a activities to R: To identify the need of close
Hyperthyroidism at C variety of condition but manage risk growth & condition supervision. (e.g.
6 the age of 16 one of its variations of the fetus or to Monitoring of fetal
E
• Takes PTU for includes c. Verbalize monitor the over-all movement & heart
hyperthyroidism P hyperthyroidism. understanding well-being. rate, vital signs)
2 • Amniotic Fluid of individual b. Perform the
T
Index (AFI) less risk factors or 3. Advice the mother to drink 3 necessary
0
than 5cm I condition(s) more oral fluids. alterations and
2 that may activities that is
O
impact R: To hydrate the suggested to
2
N pregnancy client and increase manage risk.
/ amniotic fluid c. Identify and
production. understand the
underlying risk
H 4. Explain the mother about 4 factors that may
the disease condition and affect the
E
its complication like birth pregnancy.
A defects and the need to
keep hydrated.
L
T R: To gain
knowledge and
H
identify the
importance of
keeping hydrated.
M
A 5. Encourage the mother to
take healthy food and limit 5
N
salt intake.
A
R: To maintain well
G
balanced diet for
E hyperthyroidism and
decrease the risk of
M
complications of
E both mother and
fetus.
N
T 6. Advice the client to take
adequate bed rest and 6
avoid excessive physical
exertion.

R: To prevent
further fluid loss
while performing
activities.
7. Provide a comfortable left 7
side-lying position with
pillows supported at the
sides.

R: To provide
comfort and relieve
from pain.

8. Treat the appropriate cause 8

by administering or
continuing the medication
which is the PTU.

R: To treat the
appropriate cause &
prevent
complications of
oligohydramnios.

9. Administer IV Fluid as 9
Prescribed

R: To increase fluid
volume and treat
oligohydramnios.

10. Continuously monitor the 10

vital signs of the mother
and also assess the fetal
condition. Melanie G. Cabriadas
St, N.
R: To provide
baseline data to
initiate interventions.
Reference:

NANDA (Herdman). (2021). NANDA International Nursing Diagnosis: Definitions and Classification 2021 - 2023

Nursing Care Plan on Oligohydramnios. Retrieved from: https://learnnursingeasy.co.in/

Bathula & Kathari (2022). Pregnancy with hypothyroidism and its adverse pregnancy outcomes. IAIM, 2022; 9(1): 48-53