EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
NURSING CARE PLAN
(MATERNAL RLE)
Oteda, Jan Kyle S.
BSN 2-1
Group 3
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
Please create NCP to the following scenario: Actual and potential.
1. Patient G1P0 (1001) 40 weeks AOG came in to EMERGENCY ROOM complaining of labor pains 5/10, pain radiating from back to lower abdomen,
I.E done shows 4 cm, leaking BOW for 6 hours with light green discharge. Doctors order give ampicillin 2g IV anesthesia then 1g until delivery.
Lab works CBC and UA. CBC reveals elevated wbc 17,000 and the rest are within normal limits, for UA reveals protein +2. Initial vital signs BP
160/100, rr 22 temp 36.9 pr 89 o2sat 98% fht 130s, with lower extremity edema.
ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE Evaluation
DIAGNOSIS
Subjective: Acute pain After rendering Perform a comprehensive Assessment is the After rendering
“Patient verbalized related to effects nursing assessment. Assess first step in managing nursing
pain with a scale of of labor and intervention, location, characteristics, pain. It helps ensure intervention, the
5/10 radiating from delivery process the patient’s onset, duration, frequency, that the patient patient reports that
back to lower pain will be quality and severity of receives effective pain was alleviated
abdomen” relieved or pain. pain relief. from pain score of
Objective: controlled Pain can be 5 to pain score of 3
(+) Facial grimace Acknowledge reports of aggravated with which is tolerable
(+) Irritability pain immediately anxiety and fear pain
Vital Signs: especially when pain
BP: 160/100 Monitor Vital signs is delayed. An
RR: 22 immediate response
Provide comfort measures to reports of pain may
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
such as back rub; position decrease anxiety in
for comfort; suggest use of the patient.
relaxation techniques and Vital signs are usually
deep breathing exercises affected when pain is
present.
Provide quiet and calm Promotes relaxation;
environment refocuses attention,
Document patient’s and may enhance
response to pain coping abilities.
management. Additional stressors
can intensify the
patient’s perception
and tolerance of pain
It helps the entire
healthcare team
evaluate their pain
management
strategy.
Objective: Risk for After rendering Assess the intactness of Prolonged rupture of After rendering
Leaking BOW infection related nursing amniotic membranes. amniotic membranes nursing
for 6 hours to rupture of intervention, before delivery puts interventions, the
with light membranes as the patient Perform initial vaginal the mother and patient remains
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
green evidence by: remains free examination, when the neonate at increased free of infection, as
discharge Changes in from signs of contraction pattern repeat, risk for infection. evidenced by
the color of infection. or maternal behavior Repeated vaginal normal vital signs
Vital Signs: amniotic fluid indicates progress. examinations play a and absence of
BP-160/100 role in the incidence signs and
RR-22 Wash hands and teach of ascending tract symptoms of
Elevated WBC other caregivers to wash infections. infection.
count: 17,000 hands before contact with Washing between
patient, and between procedures reduces
procedures with patient. the risk of
transmitting
Monitor temperature, pathogens from one
pulse, respiration, and area of the body to
white blood cells as another (e.g.,
indicated. perineal care or
central line care).
Give prophylactic Within 4 hours after
antibiotics when indicated membrane rupture,
chorioamnionitis
Routinely monitor fetal incidence increased
heart rate progressively in
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
accordance with the
time indicated by vital
signs.
Antibiotic may protect
against the
development of
chorioamnionitis in
women at risk.
Slightly green
amniotic fluid may
signify infection or
fetal distress
Objective: Decreased After nursing Monitor vital signs, Hypertension occurs After rendering
Blood cardiac output intervention, particularly blood pressure owing to increased nursing
pressure of related to the patient’s and pulse regularly sensitization to intervention,
160/100 and increased blood pressure angiotensin II, which patient became
Respiratory systemic will be reduced Institute bedrest with increases BP, normotensive
rate of 22 vascular back to normal patient in lateral position. promotes aldosterone throughout
Edema in the resistance as (120/80) and release to increase pregnancy
lower evidenced by: reduce edema Give antihypertensive drug sodium/water
extremities Change in such as hydralazine reabsorption from the
blood (Apresoline) PO/IV, so that renal tubules, and
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
pressure diastolic readings are constricts blood
Edema between 90 and 105 vessels.
Dyspnea mmHg Improves venous
. return, cardiac
Prepare for birth of fetus output, and
by cesarean delivery, labor renal/placental
when severe perfusion
PIH/eclamptic condition is Antihypertensive
stabilized, but vaginal drugs work directly
delivery is not feasible. on arterioles to
promote relaxation of
cardiovascular
smooth muscle and
help increase blood
supply to cerebrum,
kidneys, uterus, and
placenta.
If conservative
treatment is
ineffective and labor
induction is ruled out,
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
then surgical
procedure is the only
means of halting the
hypertensive
problems.
Objective: Ineffective After nursing Assess vital signs, An elevated blood After nursing
Blood tissue perfusion intervention, especially blood pressure. pressure of 140/90 intervention, the
pressure of related to the patient will mmHg and above patient exhibits:
160/100 and vasoconstriction exhibit: Assess patient for the would indicate a normal
Respiratory of blood a presence of edema on the hypertension blood
rate of 22 vessels. normal face, fingers, and upper Progression of pressure of
Edema in the blood extremities. edema to the upper 120/70
lower pressur extremities indicates mmHg
extremities e of Promote bed rest in a Pre-eclampsia Edema
Proteinuria +2 120/70 recumbent position To aid in secretion of confined to
mmHg sodium the lower
no Provide emotional support To establish a extremities
presenc trusting relationship No
e of Check FHR manually or and let the woman presence of
protein electronically, as indicated. voice out her fears. protein on
should Helps evaluate fetal urine
be Administer well-being.
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
detecte antihypertensive To avoid progression
d on her medications to prevent of the disease to
urine; eclampsia. eclampsia,
and hydralazine,
edema nifedipine, and
should labetalol may be
be prescribed to reduce
confine hypertension.
d to the
lower
extremiti
es only
2. G1P0 (0000) 33 weeks AOG, came to ER complaining of labor pains, non-stress test done and shows reactive, order complete bed rest without
bathroom privileges, D5W 500 ml + 4 amps ISOxSUPRINE x 12 gtts/min with hourly titration until contraction is gone. UA reveals pus cells 10-15,
rbc 0-2. Cefuroxime 1.5g ANST. As loading dose IV. Initial vital signs bp 110/70 pr88 rr 19 temp 36.5 o2sat 98% fht 150s
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ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE Evaluation
Subjective:
DIAGNOSIS
Acute pain
EMILIO AGUINALDO COLLEGE
After rendering Expedite the Side-lying position After rendering
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
“Patient came to the related to nursing Tel. Nos. (046) 416-4341-42www.eac.edu.ph
admission process and improves uterine nursing intervention,
ER complaining preterm uterine intervention, the initiate bedrest for blood flow and may the patient reports
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
about labor pains” contractions as patient will: client, using lateral decrease uterine minimized
evidenced by: report recumbent position. irritability. discomfort, and
Objective: Reports of discomfort Help client refocus, appears relaxed due
(+) Facial grimace pain or is Teach relaxation attention decreases to effectively using
(+) Irritability discomfort minimized techniques (e.g., deep muscle tension, relaxation
or breathing exercises, reduces perception of techniques
controlled. visualization, guided discomfort and
use imagery, soft music). promotes sense of
relaxation control.
techniques Monitor maternal and Reflects
, fetal vital signs. effectiveness of
effectively. interventions.
appear Administer analgesics, Mild analgesics
relaxed as indicated. decreases muscle
and will tension and
rest Document patient’s discomfort.
appropriat response to pain
ely. management.
Objective: Risk for injury After rendering Assess FHR; note Tocolytics can After rendering
33 weeks AOG (maternal and nursing presence of uterine increase FHR. nursing
FHT: 150 fetal) related to intervention, the activity or cervical Delivery may be interventions, the
Reactive non-stress preterm labor patient will changes. Prepare to extremely rapid with patient-maintained
test and tocolytic maintain possible preterm small infant if pregnancy to the
therapy pregnancy at
• VIRTUE delivery.
• EXCELLENCE persistent uterine
• SERVICE point of fetal
least to the point contractions are maturity
