Question

nursing care plan for shoulder dystocia ?

Answer 1

1 , Nursing care plan for shoulder dystocia

Risk for maternal injury

Desired outcome: patient will accomplish cervix dialatation at least 1.2 cm per hour for primi para ,1.25 cm per hour for multipara, in active phase with fetal decent at least one centimetres per hour for primary Para ,2cm/hr for multipara.

Review the history of labour ,onset, and duration

Note timing or type of medications . Avoid administration of medications and till the cervix is 4 cm dilated.

Note the condition of cervix. Monitor for amnionitis, not elevated temperature or WBC, odour and colour of vaginal discharge

Assess uterine contractile factors manually

Evaluate the current level of fatigue,as well as activity and rest Prior to onset of labour

Evaluate degree of hydration

Encourage client to void every 1-2hour

Place client in lateral recumbent position

Have emergency kit available

Use nipple stimulation to produce endogenous oxitocin

Prepare for forceps delivery as necessary

2, risk for fetal injury

Assess FHR manually, note variability periodical changes

, and baseline rate.

Note frequency of uterine contractions

Monitor fetal Descent in birth canal in relation to ischial spine.

Assess for malpositioning using leopold's maneuver and findings on internal examination

Assess for deep transverse arrest of fetal head

Note colour and amount of amniotic fluid

Risk for fluid volume deficit

Monitor vital signs

Assess lip and oral mucous membrane

Note upnormal FHR

Keep accurate intake and output

Encourage oral Fluids as appropriate

Administer fluid intravenously

Ineffective individual coping related to situational crisis evidenced by Verbalization and behaviour

Determine progress of labour

Acknowledge reality of clients report of pain

Determine anxiety level of client and partner

Discuss the possibility of discharge of client to home until active labour is established

Provide encouragement for client

Provide comfort measures and reposition , encourage ambulation as appropriate

give factual information about what is happening