Assessment Explanation Objectives Nursing Intervention Rationale Evaluation

of the
problem
Objectives: STO: Dx: Dx: Fully Met
a. Assess the a. Amniotic fluid is a
 Premature After 4 hours of amount of marker of fetal health STO:
raptured nursing amniotic fluid and thus useful for
membrane intervention, the expelled when identifying, monitoring, After 4 hours of
 Obstructe patient will: membranes and managing effective nursing
d labor rupture and complicated interventions
 No a. Be then during pregnancies. free of preventable
nutrients free contractions b. Any changes in color trauma or other
supply of b. Note the color and in amount may complications that
prev of amniotic suggest infection and may harm the fetus
enta fluid may indicate fetal Fully Met
ble Tx distress
Nursing trau c. Monitor closely Tx: LTO:
Diagnosis: ma the temperature c. Elevated temperature or
or d. Monitor FHR fever is often the first After 24 hour of
othe every 1 hour sign of infection effective nursing
r e. Monitor d. To measure the health intervention, Be free
com periodic rate and regularity of the of variable
plica changes in fetus and to determine decelerations with
tions FHR for how well the fetus is FHR within the
that severe, e. Variable decelerations normal limit
may moderate, or indicate hypoxia due to
har prolonged possible cord entrapment
m deceleration. f. These positions can
the f. Assist patient enhance fetal
fetus in changing oxygenation and can
position such improve FHR patterns
After 24 hours as upright Edx:
of nursing position, lateral g. Provides an opportunity
intervention, the recumbent, as for early intervention in
patient will: tolerated event of developing
a. Be free complications
of Edx: h. To prevent dehydration,
variable g. Instruct client which may compromise
decelerat to report any optimal uterine and
ions untoward signs placental functioning
with and symptoms and increase uterine
FHR such as vaginal irritability
within bleeding, head i. Adequate sleep is an
the ache along with essential modulator of
normal blurred vision. immune responses.
limit h. Promote fluid Adequate sleep may
intake of at provide also provide
least two quarts comfort and a relaxed
of fluid per day feel to the patient
i. Encourage
sleep and rest.