NURSING CARE PLAN

Patient’s Initials: J.N Chief Complaint: Complete uterine inversion Name of Student Nurse:
Age & Gender: 33 yrs. Old/ Female after a normal delivery complicated by shoulder Karl Adrianne C. De Guzman
dystocia with fundal implantation and without
cord traction.

Birthdate: March 23, 1988 Admitting Diagnosis: Nullipara, Pregnancy 39 Level/Block/Group:

weeks of gestation. Active First Stage Labor. 2BSN-13
Address: Dagupan City, Pangasinan, Philippines Hospital/Area:
The Medical City/ Birthing Facility
Date of Confinement: May 11, 2021 Clinical Instructor:
Belinda S. De Vera
Date: 5/11/2021

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Data:  Uterine SHORT TERM:  Adhere to facility  Established Short term:
inversion infection control, mechanisms
 Patient was After 30 minutes of After 30 minutes of
means the sterilization, and designed to
admitted healthy nursing intervention: nursing
placenta fails aseptic policies prevent
and without any intervention, the
to detach from -The patient will and procedures. infection.
complications patient was able to
the uterine display adequate  Check for other  Differential
display adequate
Objective Data: wall, and pulls perfusion as possible sources diagnosis is
perfusion as
the uterus evidenced by stable of infections such critical for
 Pregnancy 39 evidenced by
inside-out as it vital signs within as UTI (urinary effective
weeks of stable vital signs
exits. client’s normal frequency/pain, management
gestation within client’s
Treatment range. cloudy and .
 Tense and rigid normal range.
options depend odoriferous urine),  To prevent
 Facial grimace on the severity, LONG TERM: mastitis (swelling, the spread of At long term:
 Nullipara but could After 2 days of erythema, pain) or infectious
 Shoulder include respiratory organisms. After 2 days of
nursing intervention, nursing
dystocia reinserting the infection  Increased
uterus by hand, - The patient will (productive cough, intervention, the
white blood
Vital Signs taken: abdominal display decrease purulent sputum, patient was able to
cell count
  BP- 140/90 surgery or white blood cell fever) indicates an display decrease
mmHg emergency count and vital signs  Teach and infection. white blood cell
 HR- 115 bpm hysterectomy within expected demonstrate Anemia often count and vital
 RR- 22 cpm ranges. proper hand- accompanies signs within
 Temp- 38.5 washing and self- infection, expected ranges
degrees Celsius care techniques delays the
and review wound
appropriate healing, and
handling and weaken the
NURSING DIAGNOSIS
disposal of immune
contaminated system.
materials (ex:
 Risk for infection dressings, peri
pads, linens).
 Review WBC
count, hemoglobin
and hematocrit
levels.
Case Scenario for NCP

A 33-year-old Caucasian woman 39 weeks’ pregnant was admitted to our hospital in the first stage of
labor. She was healthy, nullipara and the pregnancy proceeded without complications. After 6 hours of active
phase of labor, she had a normal delivery complicated by shoulder dystocia easily resolved with the McRoberts
maneuver. The male neonate weighted 3160g and had an Apgar score of 10 at the 1st minute and 10 at the 5th
minute. Twenty minutes after delivery, without any cord traction, the placenta, with fundal implantation,
passed through the introitus. The placenta and membranes were overlaying a firm mass that was identified as
the uterine cavity and the diagnosis of complete acute uterine inversion was made.

Immediately, administration of salbutamol was initiated and the medical team started maneuvers of
manual correction of uterine inversion. Due to the unsuccessful attempts, it was decided to try the same
technique under general anesthesia, so the patient was taken immediately to the operating room. After another
attempt to reposition her uterus, without success, a laparotomy was performed. With opposing pressures in the
cervical ring through the abdominal cavity and on the uterus fundus through her vagina, the inversion was
resolved. It was not necessary to make an incision in the cervical ring. The incomplete separation of the
placenta and membranes contributed to her mild blood loss (estimated at approximately 100cc). Her blood
pressure and cardiac frequency were normal during surgery. After the uterine reversion, her uterus and adnexa
had normal macroscopic appearance. She recovered from the postoperative period without complications. A
histological examination of the placenta had no alterations and no signs of acretism. In this case, there was only
one risk factor for uterine inversion: the fundal insertion of the placenta.