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Incompetent NCP

The patient is at risk for premature cervical dilation and maternal injury. Nursing goals are for the patient to experience no vaginal bleeding after 8 hours of intervention. Interventions include closely monitoring vital signs for changes indicating infection or shock, noting presence of vaginal bleeding, leaking fluid or contractions, and notifying the physician of any abnormal findings or signs of labor. The evaluation found that after 8 hours of nursing intervention, the patient had no vaginal bleeding, meeting the goal.

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Mina Racadio
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171 views1 page

Incompetent NCP

The patient is at risk for premature cervical dilation and maternal injury. Nursing goals are for the patient to experience no vaginal bleeding after 8 hours of intervention. Interventions include closely monitoring vital signs for changes indicating infection or shock, noting presence of vaginal bleeding, leaking fluid or contractions, and notifying the physician of any abnormal findings or signs of labor. The evaluation found that after 8 hours of nursing intervention, the patient had no vaginal bleeding, meeting the goal.

Uploaded by

Mina Racadio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Assessment Diagnosis Nursing Planning Interventions Rationale Evaluation

Implication
Risk for Premature Goals: Independent: After 8 hours of
Cues: nursing intervention,
Maternal Injury cervical dilation
After 8 hours of 1. Monitor vital Changes in vital signs the patient have no
Subjective: related to previously termed nursing intervention, signs closely (e.g., elevated temperature vaginal bleeding.
“Nakikita ko may premature as incompetent the patient will or pulse, decreasing BP)
kasamang dugo cervical dilation cervix refer in a experience no vaginal may indicate infection or Goal was met.
sa napkin ko pag- bleeding. shock
ihi ko” as as manifested cervix that dilates
verbalized by the by threatened prematurely and Vaginal bleeding other
2. Note presence of
client abortion therefore cannot vaginal bleeding, leaking than slight spotting may be
amniotic fluid, or uterine sign of cervical dilatation.
hold a fetus until
Objective: contraction Leaking membranes may
term that increase herald impending delivery
- blood in urine
-G4P0 (0210) the risk to the and place client at greater
mother injury risk for infection.
V/S taken as
follows: “Maternal & child
Prompt intervention
health 3. Notify physician
lessens likelihood of
T: 36.7 nursing: care of abnormal findings or
P: 110 complications
of the signs of labor
R: 21 childbearing
Bp: 110/60 &
The procedure is not done
childrearing 4. Assess for if vaginal bleeding or
family: presence of cramping is present, if
Chapter 21 contraindications for membranes are ruptured, if
pg. 563 by cerclage procedure cervical dilation greater
Adelle
than 3 cm occurs, or if the
Pilliteri”
diagnosis of cervical
dysfunction is in question
because situation has
progressed and
spontaneous
abortion is inevitable.

A cesarean birth may be


planned if the suture is
5. Review left intact, or the suture
implication of cerclage may be removed, allowing
procedure on outcome of a vaginal delivery. Note:
delivery at term. Scar tissue may interfere
with normal intrapartal
cervical dilation and
effacement

A common side effect is


maternal/fetal tachycardia;
6. Monitor for side rare side effects include
effects of drugs used to flushing, pulmonary

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