Assessment Diagnosis Planning Interventions Rationale Evaluation

Risk for Maternal After 8 hours of

Cues: After 8 hours of  Monitor vital signs closely  Changes in vital signs ; Elevated temperature or nursing
Injury related to pulse, decreasing BP may indicate infection or
nursing intervention, the
premature shock
Subjective: intervention, the  Note presence of vaginal patient has no
“Nakakita ko cervical dilation. patient will bleeding, leaking amniotic fluid,  Vaginal bleeding other than slight spotting may be vaginal bleeding.
daghan ug kusog experience no or uterine contraction sign of cervical dilatation. Leaking membranes may
ang dugo sa akong vaginal herald impending delivery and place client at greater Goal was met.
diaper ag nangihi bleeding.  Notify physician of abnormal risk for infection.
ko” as verbalized findings or signs of labor
by the client
 Prompt intervention lessens likelihood of
 Assess for presence of complications
Objective: contraindications for cerclage
- blood in urine procedure
 The procedure is not done if vaginal bleeding or
cramping is present, if membranes are ruptured, if
 Review implication of cerclage cervical dilation greater than 3 cm occurs.
V/S taken as procedure on outcome of
follows: delivery at term.  A cesarean birth may be planned if the suture is left
intact, or the suture may be removed, allowing a
T: 37.6 C  Monitor for side effects of drugs vaginal delivery. Note: Scar tissue may interfere
used to prevent labor. Provide with normal intrapartal cervical dilation and
P: 110 bpm effacement
R: 22 cpm information to client.
Bp: 90/80 mmHg
 Complete bed rest without  A common side effect is maternal/fetal tachycardia;
bathroom previledges. rare side effects include flushing, pulmonary edema,
and congestive heart failure
 Ensure continued bedrest in  To have less effort and prevent occurrence of
supine or Trendelenburg position vaginal bleeding.
for 24–48 hr after surgery.

 Reduces pressure of presenting part on cervix.

 Administer tocolytics as
indicated. (Refer to CP: Preterm  Reduces uterine irritability by relaxing smooth
Labor/Prevention of Delivery. muscle.

 Avoid contraction stress tests  CST is contraindicated because it may result in

trauma to the uterus and cervical sutures.
(CST or OCT) for duration of the
 pregnancy

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

After 8 hours of
Subjective Deficient After 8 hours  Determine level of client’s  Provides opportunity to clarify what nursing
Data: knowledge related of nursing knowledge has been learned previously, to interventions, the
“Wala ko to interventions, identify cultural myths, and to correct patient was able
kasabot ma’am misinterpretation the patient will  Assess degree of anxiety misconceptions. to verbalize
abi nakog sakto of information. verbalize understanding of
ra akong pag understanding  Involve significant others in  Anxiety can interfere with learning her own
the discussion process.
buros” as of her own circumstances and
verbalized by circumstances treatment and
 Provide information about  Helps reinforce understanding of all
the patient. and treatment future expectations individuals involved. demonstrated
and will self-care
demonstrate  Client may experience concern about behaviour to
self-care  Identify signs and/ or whether difficulties may be maintain
Objective Data: behaviour to symptoms to be reported to encountered. pregnancy.
maintain the health care provider.
 Irritable pregnancy.3  Prompt evaluation and intervention Goal was met.
 Discuss implications of may prevent or limit complications.
 Feeling of preexisting condition and
discomfort possible impact on  To identify physical responses
pregnancy. associated with both medical and
and anxiety
emotional conditions.
 Monitor vital signs
Vital signs  To help put the client at ease.
taken as  Promote comfort measures
follows:  Establishes the plan of care. Degree of
 Determine availability of negative response and lack of or
T: 36.7 C support systems and inadequacy of support contributes
psychological response to to heightened levels of anxiety,
P: 100 bpm the event. possibly to the point of affecting
overall outcome.
R: 20 cpm  Provide information on an
ongoing basis.  Can help allay anxiety.
BP: 120/100
mmHg

VII. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Anxiety related After 6 hours  Observe patient’s behavior  Can point to the client’s level of After 6 hours of
Subjected Data: to impending of Nursing  Determine any factors that anxiety. Nursing
further contribute to the anxiety
“ Ma’am nabalaka loss of interventions,  Establishes the plan of care. Degree interventions, the
of the woman so it could be
ko sa possibleng pregnancy as the patient avoided. of negative response and lack of or patient appeared
mahitabo sa akong evidenced will appear  Monitor vital signs to inadequacy of support contributes relax and reported
anak.” As by premature relax and determine any physical to heightened levels of anxiety, that anxiety has
responses of the patient that possibly to the point of affecting
verbalized by the dilation of the will report could affect her condition. been reduced to
overall outcome.
patient. cervix. that anxiety  Convey empathy and establish manageable level
 To identify physical responses
has been a therapeutic relationship to
associated with both medical and and verbalized
Objective Data: reduced to encourage client to express her awareness of
feelings. emotional conditions.
manageable  Provide accurate information  To avoid the contagious effect or feelings of anxiety.
 Painless level and will about the situation to help transmission of anxiety. Goal was met.
vaginal verbalize client back into reality.  Helps client identify what is reality
bleeding awareness of based.
 Determine current prescribed
feelings of medications and recent drug
 These medications can heighten
 guarding anxiety. history of prescribed or over- feelings and sense of anxiety.
behaviour the-counter medications.  A history of fetal loss, the client’s
understanding of the vents and
 Review obstetric history. proposed interventions may affect
Vital signs taken
the client’s degree of anxiety.
as follows:  Review results of diagnostic
 May point to physiological sources
tests.
of anxiety.
T : 36 C
 Promote comfort measures  To help put the client at ease.
 P: 67 bpm  The nurse may respond
R: 16 cpm  Allow the behavior to belong to inappropriately, escalating the
BP : 120/80 the client; do not respond situation to a nontherapeutic
personally.
mmHg interaction.

Name of Drug Dose Mechanism of Indication Contraindication Adverse Effects Nursing Responsibilities
VIII. DRUG STUDY
Action
  Monitor continuously for pronounced
dose-related adverse effects to maternal
Generic Oral dosage Preferentially This medication is  Mild to moderate  Arrhythmia
form (tablets): preeclampsia or and fetal heart rates and maternal BP
Name: stimulates beta2- a tocolytic agent, while infusion is running.
Ritodrine receptors in uterine prescribed for eclampsia
Adults:  Report immediately any of the
smooth muscle, uncomplicated  Dyspnea
following: palpitations, chest pain,
Brand Name: premature labor.  intrauterine
10 milligrams reducing intensity infection
dizziness, respiratory distress,
Yutopar (mg) every and frequency of weakness, tremors, sweating or chills.
uterine contractions  Nausea
two hours.
After that, the and lengthening  cervix dilated 4  Instruct the patient not breast feed while
dose is usually gestation period. cm or more (in a taking this drug.
single  Vomiting
10 to 20 mg (Actions may be
every four to eliminated by beta- pregnancy)
six hours. adrenergic  Flushed and dry
antagonists.) skin
Transitory
cardiovascular
 Chest pain or
effects include tightness
increased cardiac
output, increased
maternal and fetal
heart rates, and
widening of
maternal pulse
pressure
(beta1 stimulation).
 Name of Dose Mechanism Indication Contraindication Adverse Effects Nursing
Drug Of Action Responsibilities
Makena is Body as a whole:
Generic name:Subcutaneous Hydroxyproge a progestin indicated to Do not use Makena in
Local injection site
Notify physician
reduce the risk of women with any of the
hydroxyproge injection: sterone reactions immediately of
caproate is a preterm birth in following conditions: (including erythema, urti suspected pregnancy,
sterone
275 mg/1.1 synthetic proge women with a  Current or history caria, rash, irritation, onset of vaginal
caproate mL clear stin. The singleton pregnancy of thrombosis or hypersensitivity, bleeding, or
warmth); fatigue;
yellow mechanism by who have a history of thromboembolic
fever; hot flashes/flushes
thromboembolic
solution in which singleton spontaneous disorders implications (pain or
Brand Name: single-use hydroxyproges preterm birth. The  Known or Digestive numbness of legs,
Makena auto-injector. terone caproate effectiveness of suspected breast cancer, disorders: Vomiting sudden onset of chest
reduces the Makena is based on other hormone-sensitive pain or shortness of
improvement in the cancer, or history of Infections: Urinary tract
Intramuscular risk infection
breath, sudden severe
injection: of recurrent pr proportion of women these conditions headache or
eterm birth is who delivered < 37  Undiagnosed abnormal Nervous system dizziness, visual
250 mg/mL not known. weeks of gestation. vaginal bleeding disorders: Headache, problems).
clear yellow There are no controlled unrelated to pregnancy dizziness
solution in trials demonstrating a  Cholestatic jaundice of
single-dose direct clinical benefit, pregnancy
Reproductive system and
vials. such as improvement  Liver breast
in neonatal mortality tumors, benign or malig disorders: Cervical dilati
Intramuscular and morbidity. nant, or active liver on, shortened cervix
injection: disease
Respiratory
 Uncontrolled hypertensi
disorders: Dyspnea, chest
1250 mg/5 mL on discomfort
(250 mg/mL)
clear yellow Skin: Rash
solution in
multiple-dose
vials.