Question

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 1 Actual problem AND 1 potential problem affecting the client and her baby

Except for : Fever and Hyperthermia please

2. 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

Ans) Actual problem:

- Deficient diversional activity related to prescribed complete bed rest without bathroom privileges secondary to preterm labour

Nursing Goal:

- The client will verbalize satisfying activities within normal limits

Nursing Intervention: Rationale

- Assess the level of activity- Baseline data is obtained to plan care

- Acknowledge reality of situation & feeling of client: Presence of depression, isolation may interfere with desired activity.

- Provide physical or mental diversional activities- Interventions decrease Distraction & promote learning.

- Accept hostile expressions in aggressive acting out behavior- to understand mild uterine contractions.

Potential problem:

1) Risk of fetal injury related to cord compression secondary to decreased amniotic fluid

Nursing Goal:

- The client will verbalize understanding of individual factors that contribute to possibility of fetal injury and take steps to correct situation

Nursing Intervention Rationale:

- Asess the client's level of understanding: Baseline data is obtained.

- Provide comfortable quite setting- Intervention decrease distraction & promote learning.

- Provide health teaching regarding oligohydramnios- Accurate information encourages compliance and written resources for later review and self placed

2) Decreased Cardiac Output: Inadequate blood pumped by the heart to meet metabolic demands of the body.

May be related to:

Structural factors of congenital heart defect

Possibly evidenced by

Variations in hemodynamic readings (hypertension, bounding, pulses, tachycardia, specify values)

Widened pulse pressure

ECG changes,

Arrhythmias

Murmur

Decreased peripheral pulses

Fatigue

Dyspnea

Cyanosis or absence of cyanosis

Oliguria

Squatting or knee-chest position

Desired Outcomes

Child will demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for patient; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain.

Nursing Interventions Rationale

Assess heart rate and blood pressure. Most patients have compensatory tachycardia and significantly low blood pressure in response to reduced cardiac output.

Note skin color, temperature, and moisture. Cold, clammy, and pale skin is secondary to a compensatory increase in sympathetic nervous system stimulation and low cardiac output and oxygen desaturation.

Check for peripheral pulses, including capillary refill. Weak pulses are present in reduced stroke volume and cardiac output. Capillary refill is sometimes slow or absent.

Assess for reports of fatigue and reduced activity tolerance. Fatigue and exertional dyspnea are common problems with low cardiac output states. Close monitoring of the patient’s response serves as a guide for optimal progression of activity.

Inspect fluid balance and weight gain. Weigh patient regularly prior to breakfast. Compromised regulatory mechanisms may result in fluid and sodium retention; Weight is an indicator of fluid balance.

Assess heart sounds for gallops (S3, S4). S3 indicates reduced left ventricular ejection and is a class sign of left ventricular failure. S4 occurs with reduced compliance of the left ventricle, which impairs diastolic filling.

Monitor electrocardiogram (ECG) for rate, rhythm, and ectopy. Cardiac dysrhythmias may occur from low perfusion, acidosis, or hypoxia. Tachycardia, bradycardia, and ectopic beats can further compromise cardiac output. Older patients are especially sensitive to the loss of atrial kick in atrial fibrillation.

Provide adequate rest periods Rest decreases metabolic rate, decreasing myocardial and oxygen demand.

Position child in semi-Fowler’s position. Upright position is recommended to reduce preload and ventricular filling when fluid overload is the cause; Facilitates lung expansion.

Administer oxygen therapy as prescribed. The failing heart may not be able to respond to increased oxygen demands. Oxygen saturation need to be greater than 90%.