Problem List

Number of Focus / Nursing Diagnosis

Priority

1 Hypokalemia disease as evidenced by low potassium level.

2 Risk for Infection related to Preterm Rupture of Membrane as evidenced by Watery Vaginal Discharge

3 Acute pain related to uterine contractions as evidenced by intermittent hypogastric pain

NURSING CARE PLAN 1 - Hypokalemia disease as evidenced by low potassium level.

Defining Nursing Diagnosis Scientific Analysis Goal of Care Intervention Rationale

Characteristics

“I have been Hypokalemia Potassium is an electrolyte SHORT TERM: Independent

vomiting and disease as needed primarily for
experiencing evidenced by low muscle and nerve tissue After a day of 1. Assess patient’s 1. Assessing vital
function. Hypokalemic nurse and client vital signs signs may track the
diarrhea for the potassium level.
paralysis during pregnancy interaction, the complications easier.
past few days.
has a rare occurrence. It client will be able
Now, my body manifests as acute
feels very to:
muscular weakness
weak” associated with low 2. The ECG can
-able to
potassium levels. Any 2 Monitor ECG provide useful
OBJECTIVE: pregnancy associated with demonstrate what
continuously. information for
paralysis is a high-risk she had learned
BP: 90/60 pregnancy, and must be hypokalemia.
treated as such. -demonstrate Patients receiving
HR: 96 Depletion of potassium behaviors to digitalis should be
occurs and then leads to monitor fluid monitored closely
RR:19 status and prevent for signs of digitalis
altered electrolyte balance
in the body. or limit recurrence toxicity because
TEMP: 36.5
hypokalemia
O2 SAT: 98% potentiates the
action of digitalis.
LONG TERM:
WEIGHT: 63
After 2 weeks of
G₂P₁ (1101) 3. Strict monitoring
nursing 3. Careful
of intake and
37 ²/₇ weeks intervention, the monitoring of fluid
output.
AOG patient will: intake and output is
necessary because
-Identify measures
40 mEq of potassium
Diarrhea; watery to prevent
is lost for every liter
stools times#
of urine.
episodes for two 4. Assist client in
two 4. Including client in
days hypokalemia. selecting foods rich the plan of care
in potassium as such elicits participation.
muscle -Participate in the as banana, fruit Also, potassium-rich
weakness noted treatment juices, melon, citrus foods in the diet help
upon regimen.. fruits, and fresh maintain potassium
assessment vegetables balance.
- will be able to
maintain serum
potassium levels Dependent
Laboratory within normal
results range. 1. Administer right
medications and its 1. Right medication
Decreased and dosage reduce
dosage as
potassium level more risks and
prescribed by the
of 2.5 mE complications, and
physician.
promotes efficacy.
- Intravenous
potassium - Used in the
replacement treatment of
potassium deficiency
when oral
2. Instruct in proper
replacement is not
medication use (e.g.,
feasible
with or without
meals, take entire 2. Oral antibiotics
course of antibiotic, may be continued
as prescribed) after discharge.
Failure to complete
Collaborative: medication may lead
1. Monitor BUN and
to relapse.
creatinine levels.

1. Renal function
2. Inform and should be monitored
update all the for patients receiving
assessment or potassium
changes in the replacement.
Sources: patient’s data to 2. Being an effective
the attending advocate in the care
Nurse’s Pocket Guide:
physician or of patient is
Diagnoses, Prioritized
obstetrician. important for health
Interventions, and
Rationales, Marilynn E. improvement and
Source: recovery.
Doenges, page no. 538,
Edition 13. 2. https://
nurseslabs.c
om/comfort-labor-
delivery/
NURSING CARE PLAN 2 - Risk for Infection related to Preterm Rupture of Membrane as evidenced by Watery Vaginal Discharge

Defining Nursing Diagnosis Scientific Analysis Goal of Care Intervention Rationale

Characteristics

SUBJECTIVE: Risk for Infection Risk for infection is SHORT TERM: Independent
Patient noted related to Preterm defined as at risk for being
sudden onset Rupture of invaded by pathogenic After 8 hours of 1. Assess for signs of 1. Elevations in vital
of watery Membrane as organisms. The sac nursing infection and signs accompany
vaginal evidenced by (amniotic membrane) intervention, the monitor the vital infection fluctuations,
discharges, Watery Vaginal surrounding your baby patient will be able signs. or changes in
associated with Discharge breaks (ruptures) before to: symptoms, suggest
intermittent week 37 of pregnancy. alterations in client
-Initiate behaviors status.
hypogastric Once the sac breaks, you
to limit the spread
pain every 5- have an increased risk for
of infection, as
10minutes. amniotic fluid and
appropriate, and
membrane infection.
reduce the risk of 2. Perform initial
complications. vaginal examination, 2. Repeated vaginal
OBJECTIVE: when the
-Identify examinations play a
contraction pattern role in the incidence
BP: 90/60 interventions to
repeats, or maternal of ascending tract
prevent or reduce
HR: 96 behavior indicates infections. Cleaning
risk of infection
progress. removes
RR:19 Demonstrate urinary/fecal
correct perineal contaminants.
TEMP: 36.5 O2 LONG TERM: cleaning after Changing pad
voiding and removes moist
SAT: 98% After 2 weeks of defecation, and medium that favors
nursing frequent changing
WEIGHT: 63 bacterial growth.
intervention, the of pads.
G₂P₁ (1101) 37 patient will be able
²/₇ weeks AOG to:

-Achieve timely
healing, free of
additional 3. Instruct the
 complications. proper disposal of
contaminated
linens, dressings, 3. It helps prevent

and pads. Maintain cross contamination

isolation, if
indicated

4. Identifies factors
4. Review prenatal,
thatplace client in
intrapartal, and
high risk.
postpartal record.

Dependent
1. Right medication
1. Administer right
and dosage reduce
medications and its
more risks and
dosage as
complications, and
prescribed by the
promotes efficacy.
physician.
2. Oral antibiotics
2. Instruct in proper
may be continued
medication use
after discharge.
(e.g., with or
Failure to complete
without meals, take
medication may lead
entire course of
to relapse.
antibiotic, as
prescribed)

Collaborative:

1. Inform and 1. Being an effective

update all the advocate in the care
Sources: assessment or of patient is
changes in the important for health
Nurse’s Pocket Guide:
patient’ data to the improvement and
Diagnoses, Prioritized
attending physician recovery.
Interventions, and
or obstetrician
Rationales, Marilynn E.
Doenges, page no. 538, Source:
Edition 13.
https://nurseslabs.c
om/comfort-labor-
delivery/
 NURSING CARE PLAN 3 - Acute pain related to uterine contractions as evidenced by intermittent hypogastric pain

Defining Nursing Scientific Analysis Goal of Care Intervention Rationale

Characteristics Diagnosis

SUBJECTIVE: Acute pain One unique aspect of SHORT TERM: Independent

related to childbirth is the association of
Patient noted uterine this physiologic process with After 8 hours of 1. Help the patient 1. Relaxing keeps the
sudden onset of nursing relax by advising abdominal wall from
contractions pain and discomfort. An
watery vaginal the woman to do becoming tense and
as evidenced understanding of labor pain in
discharges, intervention, the position that allows the uterus to
associated with by a multidimensional framework
intermittent provides the basis for a she is comfortable rise during
intermittent the patient will be
hypogastric pain hypogastric woman-centered approach to of. contractions without
able to:
every 5-10 pain. labor pain management that pressing against the
minutes. includes a broad range of -relax comfortably, abdominal wall.
pharmacologic and non- without minding
pharmacologic intervention about pain in the
OBJECTIVE:
strategies. hypogastric area. 2. Breathing
(+)hypogastric techniques can be
2. Coach the patient
pain radiating to considered as a
with the breathing
lumbosacral at distraction technique
techniques
back because the woman
concentrates on
(+) watery
slow-paced
vaginal
breathing instead of
discharges
LONG TERM: minding the pain.
- vital signs:
After 2 weeks of
BP: 130/80 nursing
3. Effleurage is a
intervention, the 3. Administer
HR: 92 form of therapeutic
patient will be able therapeutic touch
touch that is helpful
to: and massage
RR: 24 during the first and
- Patient’s pain will second stages of
Temp: 37.1 labor.
be relieved or
O2 sat: 98% controlled.

G₂P₁ (1101) 1. Right medication

Dependent
-Achieve timely and dosage reduce
37 ²/₇ weeks
1. Administer right more risks and
AOG healing, free of
medications and its complications, and
additional
dosage as prescribed promotes efficacy.
complications.
by the physician.
2. Oral antibiotics may
be continued after
discharge. Failure to
2. Instruct in proper complete medication
medication use may lead to relapse.
(e.g., with or
without meals, take
entire course of
antibiotic, as
prescribed)

1. Nurses function
effectively within
nursing and inter-
Collaborative: professional teams,
fostering open
1. Inform and
communication,
update all the
mutual respect, and
assessment or
shared decision
changes in the
making as they
patient’s data to the
achieve quality
attending physician
patient care
or obstetrician.

Source:

https://nurseslabs.c
om/comfort-labor-
delivery/
F (Focus): Event (admission, transfer, discharge teaching etc.) to the patient

FDAR

Date Focus Time DAR

4/03/20 Receiving of patient 04:00 pm D: Patient noted sudden onset of watery vaginal discharges, clear associated
with intermittent hypogastric pain, every 5-10 minutes. Vital Signs: BP: 90/60
HR: 96 RR:19 TEMP 36.5 OT SAT 98%

WEIGHT: 63 kg. Refer to IM for co-management RE: Hypokalemia

A: Admit under service. Secure consent to care from the patient. TPR every 4
hours. IVF: D5LR 1 L at 30 gtts/min. Monitor FHT and uterine contraction
every 15 minutes. Monitor vital signs every 4 hours. After reviewing of
history and PE, KCL drip is administered, Vitamin B complex tab, 1 banana for
meal. Decrease IVF rate to 20 gtts/min.

R: Patient is informed about the medicine given to her. She says she is
comfortable.

4/4/20 Transfer to Ward 06:10 pm

D: Patient may transfer to ward.

A: Assist patient in transferring to ward. KCL drip to consume, Reduce

mainline VF to follow to D5NM 1 L + 40 mg. Continue oral KCL and
Cefuroxine, Repeat S. potassium and Urinalysis on Monday.

R: Patient says she is comfortable and feels much better.

Discharge Planning

Date Focus Time DAR

04/05/20 Discharges 12:00 D: With discharge order from attending physician Dr. Coja
PM
instructions Activity: The client is instructed not to do light exercises and avoid heavy
chores or work and also, to avoid heavy works especially lifting and
straining heavy things that may shock the pt’s body physically. The
following are specific suggestions by the physician:

-Bed rest: The client may need to stay in bed all the time. The client will
be allowed to get up briefly to go to the bathroom. -Pelvic rest: This
means that the client should not put anything in your vagina, such as
tampons. Do not have sex. -Temperature monitoring: The client may
need to check your temperature each day to make sure you do not have
a fever. A fever may be a sign of infection.

M edication: The client knows the name, action, purpose, dose, route of
administration and side effects of each drug she is taking. The client is
instructed to report or contact the physician if adverse reactions are
present.

- Cefuroxime 500 mg/tab 1 tab BID to complete 14 days

- Vitamin B Complex 1 tab OD for 2 months

- Potasium citrate (Tascit) 12 meq/tab 1 tab OD with lunch for 2

weeks

E nvironment: The client knows the importance of having a clean,

comfortable and healthy environment free from any actual or
potential hazards. This can contribute to the client’s improvement of
her health condition. Homemaking services; and emotional and
economic support systems are in place.

T reatment: The client and family will know the purpose and action of
any treatment. Take home medications are vital for the improvement
of the client’s condition.

H ealth Teaching: Observe strict perineal care daily to avoid

contamination of perineal area. Make sure that you are sanitized and
clean when taking care of your baby to ensure your baby’s safety. Sitz
Bath: sitting in a tub of warm water for 15 minutes, two to three times
per day, will help relieve the discomfort. Do deep breathing exercise and
relaxation techniques.

O utpatient Referral: Follow up Dr. Coja at the clinic after 2 weeks

- Repeat Serum / CT and UA after 2 weeks

- For KUB Ultrasound OPD brings results upon follow up

D iet: Drink plenty of liquids. Eat foods that have protein such as milk,
cheese, meat, and fish. Eat fruits and vegetables. Avoid alcohol and
caffeine.

R: Out of the room per wheelchair with improved condition

 Bibliography (a summary of all the resources used)

Martin, P. (2020). 10 Fluid and Electrolyte Imbalances Nursing Care Plans. Nurselabs. Retrieved from: https://nurseslabs.com/fluid-
electrolyte-imbalances-nursing-care-plans

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales, Marilynn E. Doenges, Edition 13.

Castro, D. & Sharma, S. (2021). Hypokalemia, NCBI. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK48246