Question

1. Prepare a nursing care plan for a client with a condition described as preterm labor secondary to PROM
2. Formulate nursing diagnoses and nursing care interventions related to the physiologic, psychologic and emotional aspects of the pregnant client with preterm labor and PROM both actual and potential problems
3. Establish expected outcomes to meet the needs of the pregnant client with preterm labor and PROM
4. Establish criteria to evaluate the effectiveness of nursing interventions enumerated.

Mechanics

1. From a hypothetical case scenario:

A 22-year-old woman presents to the hospital at 34 weeks gestation. She is G1P1. It was an uncomplicated pregnancy until 12 hours prior to admission, she experienced escape of fluid from the vagina, non-foul smelling.

She developed fever (38.2 degrees centigrade) around 6 hours prior to admission and she currently experiencing mild to moderate uterine contractions. She was started on antimicrobial treatment per IV. FHR is 118 bpm, RR=28   PR=90 BP= 110/70

2. Identify at least 2 -3 actual nursing problems and 2 potential problems affecting the client and her baby
3. Prepare an NCP following the format:

3.1. Subjective/objective data

3.2. Nursing Diagnosis

3.3 Rationale (should indicate book sources or references)

3.4 Goals/ objectives

3.5 Nursing interventions

3.6. Scientific rationale for the interventions

3.7. Evaluation criteria

Answer 1

Actual nursing diagnosis :

1. Acute pain related to uterine contrcations as evidenced by reports of pain and muscle tension. [physiologic aspect]

2. Risk for infection related to loss of protective layer (amniotic sac) as evidenced by fern test findings. [physiologic aspect]

2. Anxiety related to situational crisis arising from threat to safety of self and fetus as evidenced by apprehension. [psychologic/emotional aspect]

Potential nursing diagnosis :

1. Risk for fetal injury related to preterm delivery. [physiologic aspect]

2. Risk for poisoning related to side effects of tocolytics and antimicrobials. [physiologic aspect]

Sample nursing care plan :

Problem : Risk for infection

subjective data : patient states fluid esacpe from vagina, mild to moderate uterine contractions.

objective data : 38.2 degree temperature suggestive of fever, B.P: 110/70mmhg, RR-28, PR-90, FHR:118. Positive fern test.

nursing diagnosis : Risk for infection related to loss of protective barrier / premature rupture of membranes as evidenced by positive fern test findings.

Reference : (please refer nursing care plan books )

Goals / objcetives : Patient will be free from signs of infection.

Patient will verbalize precautons to be taken for preventing infection.

nursing interventions :

• Assees for signs of infection every 4 hourly or as specified by the treating physician. (Rationale : To detect infection early and intervene in order to prvenet preterm labour and subsequent harm to the fetus. also, to monitor the effcet of the medications administered.)
• perform vagnial examination only of required and use sterile techniques when performing vaginal examination (rationale : to prevent entry of microorganisms)
• initiate fetal monitoring (rationale: PROM may lead to fetal distress)
• administer medications a sprescribed. (rationale: to control infection)
• provide patient education on effcets of PROM and pre trem labour (Rationale: patient will be required to be on complete bed rest and must take care to prevent infectiona and preterm delivery)