NURSING CARE PLAN

PATIENT INITIALS: CC: NAME OF STUDENT

NURSE: CMTE
AGE & GENDER: 25 YEARS OLD/ FEMALE ADMITTING DIAGNOSIS: DYSTOCIA
BIRTHDATE: JAN.20, 1996 DATE OF CONFINEMENT: DEC. 23,2021
ADDRESS: MAGTAKING BUGALLON, PANGASINAN
Subjective: Prolonged/ SHORT TERM : INDEPENDENT:
Dystocia, which - Patient will - Assess FHR manually -Detects -Patient
Mother states means difficult participate in or electronically. Note abnormal improved labor
responses, such
she is tired and labor that is interventions to variability, periodic as exaggerated pattern and/or
does not know slow and not improve labor changes, and baseline variability, reduce
bradycardia, and
how much progressing. pattern and/or rate. tachycardia, identified risk
longer she is Dysfunctional reduce which may be factor.
able to push. labor can be due identified risk caused by stress,
hypoxia, acidosis,
to abnormalities factors. or sepsis.
Objective: in uterine
contraction -After 6-8 hours - Note of the -After 6-8 hours
-Contractions
-Labor and/or lack of of nursing frequency with which of nursing
occurring every 2
prolonged to ability of the intervention, the uterus contracts. If intervention,
min or less do
over 24hours mother to patient will the frequency is fewer patient
not allow for
forcibly expel accomplish than 2 minutes, notify accomplished
adequate
- Lethargy the fetus, a cervix dilation at the doctor. cervix dilation
oxygenation of
large fetus least 1.2 cm/hr at 1.2 cm/hr for
intervillous
-fetus has not and/or an for primipara, primipara and
spaces.
descended into unusual 1.5 cm/hr for 1.5 cm/hr for
birth canal orientation of multipara in -Identify maternal multipara in
-Simple
the fetus in the active phase, factors such as active phase,
techniques (such
-uncomfortable uterus, or with fetal dehydration, acidosis, with fetal
as turning the
abnormalities in descent at least anxiety, or vena caval descent at 1
client to a lateral
- Vital signs: the pelvis such 1 cm/hr for syndrome. cm/hr for
recumbent
T= 37.4 C that the passage primipara, 2 primipara. 2
position) can
BP= 120/80 is blocked or too cm/hr for cm/hr for
sometimes
mmHg small. The latter multipara. multipara.
improve the flow
RR= 22bpm may also be due
of blood and
to a LONG TERM:
oxygen to the
-late disproportionat
uterus and
deceleration of e size of the After 1 day of After 1 day of
placenta,
the fetal heart fetus in relation nursing nursing
preventing or
rate to the size of intervention, intervention
correcting fetal
the pelvis. Labor patient will be patient was
hypoxia.
that is too rapid, free of free of any
NURSING referred to as preventable Monitor fetal descent preventable
DIAGNOSIS precipitate trauma and in birth canal in trauma and
A primipara's
labor, usually others. relation to ischial others.
descent of less
- Risk for fetal results from low spines.
than 1 cm/hr or a
injury related resistance
multipara's
to prolonged through the - After 12-14 After 10-12
descent of less
labor as hours of nursing hours of
evidenced by birth intervention, than 2 cm/hr nursing
reported fetal patient will might indicate intervention,
experience of display a fetal malposition. fetal patient
fatigue and heart rate Assess for maintained a
fetus has not within normal malpositioning In order to normal range
descended into limits, with no utilizing Leopold's determine of heart rate
birth canal. late procedures and potential and showed no
decelerations, internal examination dysfunctional decelerations
and will show results. labor, it is or distress
no distress for necessary to throughout the
the duration of determine the labor progress.
labor. fetus lie and
position within
the birth canal.
-After nursing When the membranes -The patient
intervention, rupture, look for Presenting received
the patient will apparent cord portion is not appropriate
be able to prolapse and securely medications.
receive concealed cord engaged, nor is it
appropriate prolapse, which is completely
medications. indicated by obstructing the
fluctuating os, as in vertex
decelerations on the presentation,
monitor strip, cord prolapse is
especially if the fetus more common
is in breech with breech
presentation. presentation.

Note odor and change

in color of amniotic Prolonged
fluid with prolonged rupture of
rupture of membranes can
membranes. result in infection
and sepsis, as
well as fetal
COLLABORATIVE: tachycardia.
Administer antibiotic
to client, as indicated. Prevents
infection from
spreading and
protects the
 fetus.
Prepare for birth in
the posterior position Maternal
if the fetus fails to lacerations are
rotate from the OP to more common
the OA position. when the fetus is
Alternatively, use the delivered in a
vacuum extractor as posterior
indicated. position. To
rotate and speed
up the birth of
the fetus, a
vacuum extractor
can be
performed.
Case scenario: Amanda Smith, a 25-year old admitted to a hospital “I feel tired and does not know how
much longer I able to push” as stated by Amanda Smith. Upon further assessment, it is noticeable that
she is uncomfortable and fetus has not yet descended into birth canal. While the result of her vital signs
are as follows: Temperature result was 37.4 C, Blood Pressure result was 120/80 mmHg, and Respiratory
Rate result was 22 breaths per minute