Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City, Ilocos Sur

COLLEGE OF NURSING

Nursing Care Plan

MDH OB/GYNE

SUBMITTED TO:

MS. MARIE JANE URUBIO, RN,

(Clinical Instructor, UNP-CN)

SUBMITTED BY:

TRISHA DIANNE R. RAQUENIO

(BSN 2C, UNP-CN)

 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur

College of Nursing
Website: www.unp.edu.ph Mail: unpnursingvc@yahoo.com
CP# 09177148749, 09175785986
NURSING CARE PLAN
NAME: TAN, GEMMA R.
AGE: 28 SEX: FEMALE WARD/ROOM: OB/GYNE ROOM 100

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNNOSIS BACKGROUND
Subjective: Acute pain related Lumbosacral strain After 8 hours of Independent: GOALS MET
“Sobrang sakit ng to lumbosacral is a medical term for nursing - Monitor and record - Provides
tiyan at balakang strain as evidence an injury that causes interventions, the uterine activity with information/legal After 8 hours of
ko” as verbalize by by verbalizations. low back pain. The patient will be able each contraction. documentation nursing
the patient. lumbosacral area to: about continued interventions, the
(low back) is  experience progress; helps patient was able to:
Objective: between the bottom gradual identify abnormal  experience
-weak in appearance of the ribcage and reduction / contractile pattern, gradual
-uncomfortable the top of the relief of allowing prompt reduction /
-facial grimace buttocks. A strain is pain from a assessment and relief of
-irritability tearing of muscles pain scale of intervention. pain from a
-restlessness and tendons. These 9 to at least pain scale of
-Pain scale: 9/10 tears can be very 5. - Identify degree of - Clarifies needs; 9 to at least
-Vital Signs: small but still cause  use discomfort and its allows for 5.
BP: 120/80 mmHg pain. appropriate sources. appropriate  use
PR: 88 bp, techniques intervention. appropriate
RR:18 cpm to maintain techniques
T: 36.9 ˚C control - Observe for - Anal eversion and to maintain
 rest between perineal and rectal perineal bulging control
contractions. bulging, opening of occur as the fetal  rest between
vaginal introitus, vertex descends, contractions.
and changes in fetal indicating need to
station. prepare for delivery.

- Review - Although client is

information with under the stress of
client/couple about labor and
type Review discomfort levels
information with may interfere with
client/couple about normal decision-
type stage specific making skills, she
to the delivery still needs to be in
setting (e.g., local, control and make
pudendal block, her own informed
lumbar epidural decisions regarding
reinforcement) or anesthesia.
use of
transcutaneous
electrical nerve
stimulation (TENS),
acupressure or
acupuncture.
Review advantages
and/or
disadvantages, as
appropriate.

- Monitor maternal - Maternal

BP and pulse, and hypotension caused
FHR. Observe by decreased
unusual adverse peripheral resistance
reactions to as vascular tree
medication, such as dilates is the main
antigen-antibody adverse reaction to
reactions, subarachnoid or
respiratory peridural block.
paralysis, or spinal Fetal hypoxia or
blockage. Note bradycardia is
adverse reactions possible, owing to
such as decreased
nausea/vomiting, circulation within
urine retention, the maternal portion
delayed respiratory of the placenta.
depression, and Other adverse
pruritus of face, reactions may occur
eyes, or mouth. after administration
of spinal or
peridural anesthetic
especially when
morphine is used.
- Provide - Keeps couple
information and informed of
support related to proximity of
progress of labor. delivery; reinforces
those efforts are
worthwhile and the
“end is in
sight.”

- Provide comfort - Promotes

measures, such as psychological and
mouth care; perineal physical comfort,
care/massage; clean, allowing client to
dry linen and focus on labor, and
underpads; cool may reduce the need
environment (68°F– for analgesia or
72°F [20°C– anesthesia.
22.1°C]), cool,
moist cloths to face
and neck; or hot
compresses to
perineum, abdomen,
or back, as desired.

- Encourage patient - Anesthetics may

to manage efforts to interfere with
bear down with client’s ability to
spontaneous, rather feel sensations
than sustained, associated with
pushing during contractions,
contractions. Stress resulting in
importance of using ineffective bearing
abdominal muscles down. Spontaneous,
and relaxing pelvic rather than
floor. sustained, efforts to
bear down avoid
negative effects of
Valsalva’s
maneuver associated
with reduced
maternal and fetal
 oxygen
levels. Relaxation of
the pelvic floor
reduces resistance to
pushing efforts,
maximizing effort to
expel the fetus.

- Complete
- Encourage client to relaxation between
relax all muscles contractions
and rest between promotes rest and
contractions. helps limit muscle
strain/fatigue.

- Proper positioning
- Assist client in with relaxation of
assuming optimal perineal tissue
position for bearing optimizes bearing-
down; (e.g., down efforts,
squatting or lateral facilitates labor
recumbent semi- progress, reduces
Fowler’s position discomfort, and
(elevated 30–60 reduces need for
degrees). Assess forceps application.
effectiveness of
efforts to bear down.
- Reduces
- Assist with discomfort
reinforcement of associated with
medication via episiotomy, forceps
indwelling lumbar application, and
epidural catheter fetal expulsion.
when caput is Adverse reactions
visible. Monitor include maternal
vital signs and hypotension, muscle
adverse responses. twitching/
convulsions, loss of
consciousness,
reduced FHR, and
beat-to-beat
variability.
 - Promotes comfort,
facilitates fetal
- Assess bladder descent, and reduces
fullness. Catheterize risk of bladder
between trauma caused by
contractions if presenting part of
distension is noted fetus.
and client is unable
to void. - Anesthetizes lower
two-thirds of vagina
- Position client in and perineum
dorsal lithotomy during delivery and
position and assist for episiotomy
as necessary with repair. May interfere
administration of with efforts to bear
pudendal anesthetic. down but has no
effect on maternal
BP, FHR, or FHR
variability.

- Anesthetizes
perineum tissue for
- Assist as needed incision/repair
with administration purposes.
of local anesthetic
just before
episiotomy, if done.
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur

College of Nursing
Website: www.unp.edu.ph Mail: unpnursingvc@yahoo.com
CP# 09177148749, 09175785986
NURSING CARE PLAN
NAME: TAN, GEMMA R.
AGE: 28 SEX: FEMALE WARD/ROOM: OB/GYNE ROOM 100

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNNOSIS BACKGROUND
Subjective: Risk for infection Rupture of the After 8 hours client Independent: GOALS MET
The patient related to ruptured membranes is will be able to: - Monitor vital - The incidence of
experienced a membrane as commonly  demonstrate signs, and white chorioamnionitis After 8 hours client
sudden splash of evidenced by described as “the techniques blood cell (WBC) (intra-amniotic was able to:
water. sudden splash of water breaks.” to minimize count, as indicated. infection) increases  demonstrate
water. When the risk of within 4 hours after techniques
Objective: membranes break, infection. rupture of to minimize
-Vital Signs: the fluid within the  be free of membranes, as risk of
BP: 120/90 mmHg membranes around signs of evidenced by infection.
PR: 86 bpm the fetus (amniotic infection elevations of WBC  be free of
RR: 18 cpm fluid) flows out (e.g., count and abnormal signs of
T: 37.2 ˚C from the vagina. afebrile; vital signs. infection
FHT: 138 bpm The flow varies amniotic (e.g.,
-Progress of labor: from a trickle to a fluid clear, - Perform initial - The incidence of afebrile;
Duration- 55 secs gush. As soon as the nearly vaginal chorioamnionitis amniotic
Interval- every 3 membranes have colorless, examination; repeat (intra-amniotic fluid clear,
mins ruptured, a woman and only during infection) increases nearly
Freq- 5 mins should contact her odorless). contractile pattern or within 4 hours after colorless,
Intensity- moderate doctor or midwife. client’s behavior rupture of and
indicates significant membranes, as odorless).
progress of labor. evidenced by
elevations of WBC
count and abnormal
vital signs.

- Use aseptic - Helps prevent the

technique during a growth of bacteria;
vaginal limits contaminants
examination. from reaching the
vagina.
- Demonstrate good
hand washing - Reduces risk of
techniques. acquiring/spreading
infective agents.
- Assess vaginal
secretions using - Spontaneous
phenaphthazine rupture of
(nitrazine paper). membranes 1 hr or
Perform more before the
microscopic onset of labor
examination for increases the risk of
positive ferning. chorioamnionitis
during the
intrapartal period.
Color changes of
nitrazine paper from
yellow to dark blue
indicate presence of
alkaline amniotic
fluid; ferning
indicates rupture of
membranes. Note:
Excess bloody
show, which is more
alkaline than vaginal
secretions, may
cause similar
changes on nitrazine
paper.
- Monitor and
describe the - The amniotic fluid
character of during an infection
amniotic fluid. becomes thicker and
yellow-tinged and
has a foul-smelling
odor.
- Provide oral and
parenteral fluids, as - Maintains
indicated. hydration and a
general sense of
 well-being.

- Encourage perineal - Reduces risk of

care after ascending tract
elimination and prn infection.
as indicated; change
underpad/ linen
when wet.

Dependent:
- Carry out perineal - Some providers
preparation, as believe it may
appropriate. facilitate perineal
repair at delivery
and cleaning of the
perineum in the
postpartal period,
thereby reducing the
risk of infection.

- Obtain blood - Detects and

cultures if identifies causative
symptoms of sepsis organism(s).
are present.

- Administer - Although not often

cleansing enema, if done, bowel
indicated evacuation may
promote progression
of labor and reduce
risk of infection
caused by
contamination of the
sterile field during
delivery.

- Administer - Although
prophylactic antibiotic
antibiotic IV, if administration
indicated. during the
intrapartal period is
controversial
 because of antibiotic
load for the fetus, it
may help protect
against development
of
chorioamnionitis in
the client at risk.

- Administer - If labor does not

oxytocin infusion, as happen within 24
ordered. hours after rupture
of membranes, an
infection may occur.
If client is at 36
weeks’ gestation,
onset of labor
reduces risk of
negative effects on
client/fetus.