Question

Careplan for Brenda patton

Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor assessment.

The patient states that her water may have broken earlier this morning and she thinks she is in labor. AmniSure was positive. Vaginal reveals 50% effacement of cervix, cervical dilation 4 cm, and fetus at -2 station.

The patient's boyfriend is present, and she has phoned her mother to inform her of her admission. The provider has been notified, and prenatal records have been pulled.

The lab report indicates that the patient's group B strep vaginorectal culture taken at 36 weeks was positive. The patient wishes to have a natural birth without medication. Admission intrapartum orders have been initiated, initial labs have been drawn, and a saline lock has been placed in her forearm.

Answer 1

Answer: Care plan for Brenda Patton

Labor is defined asa series of rhythmic,involuntary,progressive uterine contraction that causes effacement and dilation of the uterine cervix.There are three stages in the process of labor and delivery.

The first stage is the longest involves three phases,namely latent,active and transition.The onset of regular uterine contraction until cervical dilation is the latent phase,when cervical dilation is at 4 to 7 cm and contraction last from 40-60 seconds with 3-5 minutes is the active phase and transition phase occurs when contractions reach their peak with 2-3 minutes intervals and dilation of 8 - 10 cm.

The second stage of labor starts when cervical dilation reaches 10 cm and ends when the baby is delivered.

Third stage begins right after the birth of the baby and ends with the delivery of the placenta.

Brenda Patton is in the early stage of active phase in the first stage of labor with 50% effacement and 4 cm dilation of the cervix and fetus at -2 station

Nursing care plan for Labor first stage - Active phase

Nursing Diagnosis:

1) Acute Pain evidenced by restlessness,muscle tension,verbalizations.

Nursing Interventions:

• Assess degree of discomfort through verbal and non verbal cues.Rationale: The reactions to pain varies with individuals and past experiences.
• Assess nature and amount of vaginal show,cervical dilation,effacement,fetal station,and fetal descent. Rationale: Cervical dilation should be approximately 1.2 cm/ hr in nullipara and 1.5 cm / hr in multipara. Vaginal show increases with fetal descent.
• Recored time,frequency,intensity and duration of uterine contraction pattern.Rationale: Monitor the Progress of labor and provide information for the client.
• Monitor FHR to find any alterations and should be investigated thoroughly.
• Support clients decision about no use of medication in a nonjudgmental manner and encourage for efforts and use of relaxation techniques.Enhances sense of control and may decrease need for medication.

2) Impaired Urinary elimination: evidenced by changes in amount/ frequency of voiding,slowed progression of labor,urine retention,urinary urgency

Nursing interventions:

• Record and compare intake and output.Note amount,color,concentration and specific gravity of urine.Rationale: Approximate intake and outputs.Increased output may reflex excessive fluid retention prior to the onset of labor,decreased output may occur with dehydration,hemorrhage and PIH
• Assess dryness of skin and mucous membranes to evaluate degree of hydration.
• Palpate above the symphysis pubis to detect presence of urine in bladder and degree of fullness
• Position client upright,run water from the faucet,pour warm water over the perineumto facilitie voiding/ emptying of the bladder
• Encourage periodic voiding at least every 1-2 hr
• Catheterize as indicated

3) Risk for Impaired fetal gas exchange:

Nursing Interventions:

• Assess FHR Changes during contractions and accelerations to detect severity of hypoxia and possible causes like cord prolapse,prolonged head compression or uteroplacental insufficiency
• Note and record color,amount,and odor of amniotic fluid and time of membrane rupture.Rationale: In a vertex presentation prolonged hypoxia results in meconium stained amniotic fluid .Hydraminos may be associated with fetal anomalies.
• Monitor fetal descent through vaginal examination,in breach presentation assess FHR more frequently
• Check FHR immediately if membrane rupture,and again 5 minutes later,observe for visible cord prolapse to detect fetal distress due to visible or occult cord prolapse
• Place client in lateral recumbent position to correct perfusion caused by uteroplacental insufficiency
• Administer Oxygen as indicated,increases available oxygen for placental transfer

4) Risk for maternal injury

Nursing interventions:

• Monitor temperature and pulse,increased temperature and pulse are indicators of infection
• Monitor urine for ketones,indicator for metabolic acidosis
• Offer clear liquids or ice chips,as appropriate ,avoid solid foods,inhibit digestion during labor,risk of aspiration