MULTIPLE GESTATION

A Nursing Care Plan Presented to the Nursing Department of San Pedro College
In Partial Fulfillment of the Requirements in NCM-207 RLE
DELIVERY ROOM NURSING ROTATION

Submitted to:
MRS. JENNIFER YBAÑEZ, RN, MAN
Clinical Instructor

Submitted by:
XYRELCREIZ JULLIAN E. PLOYA ST. N
BSN-2Q – GROUP 5

NOVEMBER 29, 2022

SCENARIO:
A 24 years old pregnant woman, primigravida with gestational age of 18 weeks and 5 days came to San Pedro Hospital with complaint of
crampiness. Her LMP was July 21, 2022, and the Estimated Date of Confinement will be on April 27, 2023. She called the nurse and said
“natatakot at kinakabahan ako kapag naga cramps ako baka mapano yung baby ko dahil sa condition ko”. Upon assessment, VS were taken.
Temp: 37.3 C, BP: 135/90mmHg, PR: 95, and RR: 22/minute. Quivering voice, restlessness, narrowed focus, sweating and facial flushing are
manifested. She was an unbooked patient. She got her first ultrasound (level II) done at 18 weeks which revealed monochorionic diamniotic
intrauterine live twins. Placenta was anterior with grade II maturity.
Name of Patient: S.M.C Age: 24 yrs old/female Ward: St. Anne Room & Bed no #: 217-1
Chief Complaint: Anxiety Physician: Dr. Zede Diagnosis: Twin-Twin Transfusion Syndrome with manifestations of cervical insufficiency

DATE CUES NEE NURSING PATIENT NURSING IMPLEM EVALUA

/ D DIAGNOSIS OUTCOME INTERVENTIONS ENTATIO TION
TIME N
November 25,
Subjective Cues: Anxiety related to Within 8 hours • Review physiological 4 2022
N “Nurse, pag S premature cervix of holistic or psychological at
O sumasakit ang E dilation as evidenced nursing care, factors. 3:00pm
V balakang ko L by the awareness of the patient will
E natatakot at F physiological be able to: R: These elements may GOAL
M kinakabahan ako ng P symptoms. contribute to or aggravate PARTIALLY
B sobra kasi baka E 1. The client anxiety. Every time a MET
E mapano yung anak R Rationale: will be at client experiences
R ko dahil sa condition C A cervix that dilates ease and trauma, these worries or After 8 hours of
ko ngayon. Di ko E early and is unable to report that psychological problems nursing
2 alam anong gawin P carry a pregnancy to their anxiety will resurface and alter intervention:
5 ko” T term is said to have has how they see the present
I cervical insufficiency, decreased circumstance. A study of 1. The client
2 O also known as an to a an unusual pregnancy or was able to
0 Objective Cues: N incompetent cervix or manageabl birth was revealed to be report that
2 - premature cervix e level. the primary factor their anxiety
2 - VS taken: S dilatation. Congenital 2. The client impacting anxiety and has
• Temp: 37.3C E risk factors for cervical will sadness in the first and decreased
@ • BP: L insufficiency include verbalize second trimesters among to a
7 135/90mmH F exposure to awareness pregnant women with manageabl
: g C diethylstilbestrol at of feelings cervical insufficiency (Wu e level.
0 • PR: 95 bpm O birth, uterine of anxiety. et al., 2022). 2. The client
0 • RR: N malformation, collagen 3. The client verbalized
22/minute C abnormality, collagen will identify • Administer prescribed 3 her
A - Quivering voice E vessel loss, and healthy medication by the awareness
M - Restlessness P Mullerian abnormality. ways to deal physician for cervical of feelings
- Narrowed Focus T Acquired risk factors with and insufficiency. of anxiety.

- Sweating and include a history of express 3. The client

Facial flushing preterm birth or anxiety. R: Progesterone reduces was able to
noted pregnancy loss in the 4. The client risk for preterm birth and identify
third trimester as well will short cervix healthy
as uterine cavity demonstrat ways to deal
surgery that e problem- • Monitor Vital Signs, 2 with and
necessitates cervical solving especially blood express
dilatation, such as skills. pressure. anxiety.
curettage and
evacuation. The R: Stress hormones are 4. The client
probability of cervical released by the body, was able to
insufficiency is also which causes anxiety. demonstrat
influenced by cervical Additionally, these e problem-
lacerations brought on hormones cause a rise in solving
either delivery or heart rate and blood skills.
surgical abortion (Han vessel constriction. The
et al., 2020). client's blood pressure
Women would can rise as a result of XYRELCREIZ
JULLIAN E. PLOYA
experience significant these changes. ST.N

changes not only in

their physiological but • Determine the coping 8
also in their skills utilized by the
psychological states client in the past.
during the pregnancy.
Previous research R: Examine with the client
showed that 22.9% of how she handled stressful
pregnant women situations in the past,
experience anxiety, before the current
while up to 11.9% of circumstance. This could
pregnant women may aid the client in regaining
be diagnosed with control and
depression. Pregnancy understanding the
loss at this point can be significance of the
extremely damaging trauma.
since pregnant women
can develop a close • Assess psychological 1
bond with their unborn indicators of anxiety:
children through the BP, pulse, respiratory
fetal heartbeat and fetal rate, diaphoresis
movement throughout
the second trimester. R: Changes in Vital Signs
Depression and anxiety in the psychological
problems during aspect of the client is
pregnancy can have dependent to a
detrimental effects on psychological origin .
mothers, their unborn Anxiety needs to be
children, and their distinguished from
families (Wu et al., physical issues. Physical
2022). signs includes; chest
discomfort, numbness, or
Reference: headaches.
Han, Y., Li, M., Ma, H., Psychological reactions
& Yang, H. (2020, July might include shock,
21). Cervical denial, panic attacks,
insufficiency: a severe anxiety, and
noteworthy disease anger.
with
controversies. Journal
of Perinatal • Observe the client’s 7
Medicine, 48(7), 648- behaviors. Note the
655. degree of
disorganization.
Wu, Q., Chen, J., Zou,
Q., Zeng, X., Yang, Y., R: The client may require
Zhou, Y., He, G., Luo, more intense examination
C., & Wu, F. (2022, and intervention since
April 06). An Analysis they may not be able to
on the Factors for manage activities of daily
Cervical Insufficiency living (ADLs) or
Causing Adverse workplace demands. As a
Emotions Among major negative life event,
Pregnant Women at spontaneous abortion
Different Gestation may add to the client's
Phases. Frontiers in psychological burden,
decrease their interest in
Psychiatry, 13(764345) other pursuits, and create
. a barrier in their path to
social interaction, which
can increase
interpersonal conflict and
indifference, lower self-
esteem, and heighten
feelings of frustration,
loneliness, and guilt.

• Establish a 5
therapeutic
relationship,
conveying empathy
and unconditional
positive regard.
Maintain a calm
manner while
interacting with
patient.
R: Therapeutic nurse-
client relationship allows
them to work together
efficiently. With that, the
established safe
atmosphere fosters
honest sharing of
thoughts, emotions, etc.,
makes the client
comfortable and secured.

• Engage the client in 9

learning new coping
behaviors, such as
progressive muscle
relaxation and thought
stopping.

R: The ability to handle

and deal with stress can
be improved by
substituting maladaptive
habits. In contrast to
extended ruminating over
the circumstance, which
can actually slow
recovery, interrupting
obsessive thought
enables the client to
employ energy to address
underlying worry.

• Provide accurate 10
information about the
circumstance.

R: Trust in health services

is proven to be impacted
by health experts'
conflicting
recommendation. Updat
e the client frequently on
their progress to assist in
the reduction of anxiety
caused by the
uncertainty.

• Encourage the client 11

to develop an activity
program.

R: By easing tension, this

could help to lower
anxiety levels.
Acupressure,
visualization, breathing
exercises, reflexology,
yoga, and meditation are
a few complementary and
alternative therapies that
may aid in the client's
relaxation and reduction
of anxiety.

• Arrange for continuity 12

of care and follow-up.
R: Building a trusting
connection between a
client and a practitioner
requires continuity of
service and follow-up
screening. According to
other research, women
are more likely to seek
therapy if they have
continuity of care, which
may increase the uptake
of perinatal mental health
treatments. Consistency
in treatment enables the
development of a trusting
relationship and offers
continual chances for
openness, reflection,
counseling, and
intervention.
 • Identify the client’s 6
perception of the
threat represented by
this occurrence.

R: The ambiguity of the

outcome aggravates
anxiety. The client fears
losing their child and is
swayed by considerations
of gain and loss. This is
bad for their physical and
mental health. Even the
slightest hint may make
the client nervous.

REFERENCES
Bansal R, Kaur J, Priyanka (2020). Twin-Twin transfusion syndrome: a case report. Int J Reprod Contracept Obstet Gynecol
Brown, R., Gagnon, R., & Delisle, M.-F. (2019, February). No. 373-Cervical Insufficiency and Cervical Cerclage. Journal of Obstetrics and
Gynaecology Canada, 41(2), 233-247.