Question

Pls i need a detail two care plans with 2 nursing diagnosis for the case scenario below

Rosie is a primigravida at 43 weeks of gestation. Her labor is being stimulated with oxytocin administered IV. Her contractions have been increasing in intensity with a frequency of every 2 to 2 ½ minutes and a duration of 80 to 85 seconds. She is currently in a supine position with a 30-degree elevation of her head. On observation of the monitor tracing, you note that during the last two contractions, the FHR decreased to 120 BPM after the contraction peaked and did not return to baseline of 155 BPM until about 10 seconds into the rest period. A slight decrease in variability and baseline rate was observed. Write a nursing care plan for Rosie.

Your care plan should consist of detailed assessment data pertaining to the client. This includes goals,2 nursing diagnosis, 3 nursing interventions with a rational for each, and expected outcomes.

Answer 1

Answer :

Nursing care plan 1.

Assessment :

Subjective data : client hasbeen complaints about severe pain, and I can't able to tolerate this pain, feeling bad.

Objective data : chronic pain or severe pain , uterine contractions increased intensity and frequency.

Nursing diagnosis :

Chronic pain related to uterine contractions and decent of the fetus, as evidenced by client verbalization and crying due to pain.

Goal or expected out come :

Pain may be reduced after delivery of the baby and by decreasing uterine contractions.

Planning :

* assess vital signs of mother.

* assess intensity frequency and duration of uterine contractions.

* provide comfortable position.

* assess fetal heart rate.

* provide psychological and emotional support.

Implementation and rationale :

* assessed vital signs of mother, temperature is 98.8 degree foreign heat, pulse 84 b/ mit and blood pressure is 128/88 mm of hg and respiratory rate is 24 b / min.

It will give baseline information to plan nursing interventions.

* assessed uterine contractions frequency every 2 - 2 1/2 min, direction 80 - 85sec, so it indicates severe contractions.

To know the severity of contractions, more than 60 sec pain may cause for fetal distress.

* provided comfortable position that is lethotomy position is comfortable during second stage of labour.

It will useful to reduce the pain by maintaining mother comfort ness.

* fetal heart rate is 120 beats per minute, it indicates fetus is going to distress,

Fetal heart rate monitoring is very important during labor process to maintain fetal well being, normal is 120 - 160 b/ min.

* provided psychological and emotional support, to reduce some what pain of mother, because here we should not administer analgesics because it is a process to deliver the baby, after delivery the pains may come down.

Evaluation :

After nursing interventions and finishing labour process the client may reduced from labour pains, now she is feeling comfortable.

Nursing care plan 2.

* Assessment :

Subjective data : client complaining about she is having fear and worriying about her condition.

Objective data : fear and anxiety

Nursing diagnosis :

Fear and anxiety related to delivery process as evidenced by client verbalization and asking many doubts.

Goal or expected out come :

To reduce client fear and anxiety by implementing nursing interventions.

Nursing interventions and rationale :

* assess the client blood pressure, checked blood pressure 128/ 88 mm of hg, some times due to anxiety and stress the blood pressure may increases, it is problematic to mother and baby,

So it is used to know base line data to plan interventions.

* monitors fetal heart rate and uterine contractions every 15 min once, to reduce the risk of mother and baby, here baby will not improve from 120 to high it may need further interventions like cesarean section.

* explained mother to breathing technique while she is having severe contractions so it may used for reduce pain and provide comfort.

* provide information regarding progress of the labour to the mother and couple, to reduce anxiety.

* provided frequent positive encouragement to reduce anxiety and fear.

Evaluation :

After implementation of nursing interventions the family and client may reduced from fear and anxiety.