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    Nursing Diagnosis Objectives Interventions Rationale Evaluation

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    Danica Fave Andiam
    This nursing care plan addresses the risk of maternal infection due to prolonged ruptured amniotic membranes. The objectives are to monitor for signs of infection and prevent the spread of bacteria. Interventions include frequent monitoring of vital signs and vaginal exams using aseptic technique. The rationale is that membrane rupture increases the risk of chorioamnionitis within 4 hours, so careful monitoring and prevention of infection is important.

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    Nursing Diagnosis Objectives Interventions Rationale Evaluation

    Uploaded by

    Danica Fave Andiam
    16 views3 pages
    This nursing care plan addresses the risk of maternal infection due to prolonged ruptured amniotic membranes. The objectives are to monitor for signs of infection and prevent the spread of bacteria. Interventions include frequent monitoring of vital signs and vaginal exams using aseptic technique. The rationale is that membrane rupture increases the risk of chorioamnionitis within 4 hours, so careful monitoring and prevention of infection is important.

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    1st_Stage_of_Labor__NCP_

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    This nursing care plan addresses the risk of maternal infection due to prolonged ruptured amniotic membranes. The objectives are to monitor for signs of infection and prevent the spread of bacteria. Interventions include frequent monitoring of vital signs and vaginal exams using aseptic technique. The rationale is that membrane rupture increases the risk of chorioamnionitis within 4 hours, so careful monitoring and prevention of infection is important.

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    © All Rights Reserved
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    Flag for inappropriate content
    Download as docx, pdf, or txt
    16 views3 pages

    Nursing Diagnosis Objectives Interventions Rationale Evaluation

    Uploaded by

    Danica Fave Andiam
    This nursing care plan addresses the risk of maternal infection due to prolonged ruptured amniotic membranes. The objectives are to monitor for signs of infection and prevent the spread of bacteria. Interventions include frequent monitoring of vital signs and vaginal exams using aseptic technique. The rationale is that membrane rupture increases the risk of chorioamnionitis within 4 hours, so careful monitoring and prevention of infection is important.

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    of 3

    NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

    The incidence chorioamnionitis (intra-


    Risk for maternal infection related At the end of nursing  amniotic infection) increases within 4
    to prolonged ruptured amniotic interventions, the client will  Monitor vital signs, and chorioamnionitis (intra- At the end of nursing hours after rupture of membranes, as
    zed by membrane. be free of signs of infection white blood cell (WBC) count, amniotic infection)
    (e.g., afebrile; amniotic fluid as indicated. increases within 4 hours interventions, the client was evidenced by elevations of WBC count
    clear, nearly colorless and after rupture of free from signs of infection and abnormal vital signs.
    odorless). Perform initial vaginal membranes, as evidenced (e.g., afebrile; amniotic fluid Frequent vaginal examinations can lead
     by elevations of WBC count
    examination; repeat only clear, nearly colorless and to the incidence of ascending tract
    during contractile pattern or and abnormal vital signs.
    odorless). infections.
    client’s behavior indicates  Frequent vaginal Helps prevent the growth of bacteria;
    significant progress of labor. examinations can lead to limits contaminants from reaching the
    the incidence of ascending
     Use aseptic technique during tract infections. vagina.
    a vaginal examination. Reduce risk of acquiring/spreading
     Helps prevent the growth infective agents.
    Demonstrate good hand of bacteria; limits
     contaminants from Spontaneous rupture of membranes 1
    washing techniques.
    reaching the vagina. hour or more before the onset of labor
    Assess vaginal secretions increases the risk of chorioamnionitis
      Reduces risk of
    using phenaphthazine acquiring/spreading during the intrapartal period. Color
    (nitrazine paper). Perform infective agents. changes of nitrazine fluids paper from
    microscopic examination for yellow to dark blue indicate presence
    positive ferning.  Spontaneous rupture of of alkaline amniotic fluid; ferning
    membranes 1 hr or more
    before the onset of labor indicates rupture of membranes. Note:
     Monitor and describe the
    character of amniotic fluid. increases the risk of Excess bloody show, which is more
    chorioamnionitis during alkaline than vaginal secretions, may
    the intrapartal period.
     Provide oral and parenteral Color changes of nitrazine cause similar nitrazine pape

    This study source was downloaded by 100000781299023 from CourseHero.com on 12-04-2021 01:18:33 GMT -06:00
    Encourage perineal care after elimination and prn as
    indicated; change under pad/linen when wet.
    Carry out perineal preparation, as appropriate.
    Obtain blood cultures if symptoms of sepsis are fluids, as indicated. paper from yellow to dark
    present. blue indicate presence of
    Administer  alkaline amniotic fluid;
    elimination and prn as ferning indicates rupture of
    indicated; change underpad/ membranes. Note: Excess
    linen when wet. bloody show, which is
    more alkaline than vaginal
    secretions, may cause
     Carry out perineal similar changes on
    preparation, as appropriate. nitrazine paper.

     Obtain blood cultures if 


    symptoms of sepsis are The amniotic fluid during an infection
    present. becomes thicker and yellow-tinged and has .
    a foul-smelling odor.
    Administer cleansing enema, Maintains hydration and a general sense of
     
    if indicated. well- being.
     Administer prophylactic Reduces risk of ascending tract infection.
    antibiotic IV, if indicated. Some providers believe it may facilitate
     repair at delivery and cleaning of
    perineal
     Administer oxytocin infusion, the perineum in the postpartum period,
    as ordered.
    thereby reducing the risk of infection.
    Detects and identifies causative
    organism(s).

    This study source was downloaded by 100000781299023 from CourseHero.com on 12-04-2021 01:18:33 GMT -06:00
    Although not often done,

    bowel evacuation may
    promote progression of labor
    and reduce risk of infection
    caused by contamination of the
    sterile field during delivery.
    . antibiotic
    Although
    administration 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.
    If labor does not happen within
    24 hr 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.

    This study source was downloaded by 100000781299023 from CourseHero.com on 12-04-2021 01:18:33 GMT -06:00

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