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90 MATERNAL-INFANT NURSING CARE PLANS 9 atent base ctive base ransition Stage N&th Stage * Stage Assessments Admission assessment, v/s, vaginal exam prn nitrazine/ fern urine dip for protein, U/A, CBC con tractions EFM X 20 min B/P, P, R, and FHR assessment q lh (low risk) q 30” (high risk) Temp q 4h until ROM then q 2h B/P, P, R, ctx 86 FHR assessment q 30” (low risk) q 15” (high risk) Vag exam as needed I Observe show, signs bloody of 2nd stage: grunting, pushing, hiccoughs, emesis B/P, P, R, ctx & Fetal response to pushing q 15” (low risk) q 5” (high risk) Time of birth Apgar @ 1&5 min Time, maternal B/Pt P, R Temperature B/P, P, R, fundus/ lochia, episiotomy & bladder checks q15 min X 4, q 30 min X 2, qh X2 then routine infant physical exam, Gestational age assessment Activity Ambulation if membranes intact or with SROM and head engaged Ambulation if desired, rocking chair, bed on L side Bedrest or chair as desired, hands & knees for OP Squatting or side lying to push; avoid breath-holding or supine position As desired 4 Comfort Teaching Explain all procedures & equipment, include S/O and family Review/ teach breathing and relaxation techniques for labor Assist with breathing 86 relaxation, whirlpool, massage, music, birth ball, medications as desired back pressure for OP, effleurae as-4 desired Teach physiologic 2nd stage. Describe sensations Cool wash cloth, perineal massage allow to hold infant if stable----+-- Breast feeding, bonding with family Encourage voiding Peri care, ice pack if needed Other Social service consult as indicated Anesthesia epidural if desired Notify physician or CNM & prepare for delivery for multipara Notify physician, CNM & prepare for delivery as indicated As needed Oxytocics after placenta Infant: eye prophylaxis, vitamin K wt., length Arm/leg bands, footprints, fingerprints | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 91 Vaginal Bilth The nursing care plan is based on a thorough review of the prenatal record, nursing admission assessment, and continual assessments during labor. Specific client-related data should be insert- ed wherever possible. Nursing Care Plans Health Seeking Behaviors: Labor Related to: Desire for a safe labor and vaginal birth of a healthy newborn. Defining Characteristics: Client seeks medical care for perceived signs of labor. Client states (specify: e. g., “I think I'm in labor; my water broke; is my baby okay?”). List appropriate subjec- tive/objective data. Goal: Client continues health seeking behaviors throughout pregnancy. Outcome Criteria Client will verbalize agreement with the plan of care for labor (specify: EFM, IV, birth plan requests, etc. ). Client participates in self-care dur- ing labor. INTERVENTIONS RATIONALES Interview client alone. Establish rapport, ensure privacy, listen attentively and observe nonverbal cues (provide an inter- preter prn). Assess client's chief com-Assessments need to be plaint (reason for seeking adapted to client condition care). with prioritization of activ- ities. Privacy allows client to provide information and express concerns openly. INTERVENTIONS RATIONALES If in active labor, quickly assess stage of labor and fetal well-being; notify caregiver of client's status. Assess client's knowledge of labor and birth (child- birth classes, other births she's experienced). Ask client who she would like to have present during her labor and birth. Allow family to be present as client wishes. Teach client and signifi- cant others about equip- ment (specify: e. g., EFM) and procedures (specify: e. g., labs, rv) that have been ordered by her care- giver. Explain rationales for each. Allow time for questions. Modify plan of care based on client's requests (e. g., female caregivers only) if safe to do so. Collaborate with caregiver for changes in routine orders (specify: e. g., no enema, no EFM). Teach (review) stages and phases of labor with client. Inform client of her cur- rent status and how her baby is adapting to labor. Inform client of timing of routine vital signs and fetal assessments, and when vaginal exams might be done. Orient client to the setting (call lights, phone system, etc. ) and show Assessment provides infor- mation about individual learning needs. The nurse acts as a client advocate in allowing desired support people and keeping others out of the client's room. Teaching empowers client and significant other to become participants in labor and birth. Modifying routine care shows respect for the client as an individual with the right to participate in deci- sions regarding care. Information helps client to evaluate how she feels compared to her labor sta- tus, and provides reassur- ance that her baby is also being cared for. Information about expect- ed interventions helps the client understand what is happening. Knowledge empowers the client to control aspects of her envi- ronment to I' comfort during labor. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
92 MATERNAL-INFANT NURSING CARE PLANS ~~ INTERVENTIONS RATIONALES how she may adapt it for comfort (e. g., lighting switches, thermostat, extra blankets, etc. ). Encourage client to stay out of bed as long as possi- ble to allow position to help advance her labor. Provide non-skid slippers and robe for ambulation, suggest rocking chair when she is tired of walking (birthing ball or whirlpool if available-specitj. use). Provide emotional support and praise as needed to encourage client and sig- nificant other to cope with the demands of labor and birth. Encouragement promotes healthy behaviors to facili- tate the progress of normal labor. Emotional support and praise reinforce client and significant other's sense of control during labor. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does client verbalize agreement with the plan of care for labor? [Specify EFM, IV, birth plan requests etc. ]. (Does client participates in self-care during labor? Specifjr: e. g., walking, etc. ) (Revisions to care plan? D/C care plan? Continue care plan?) Management of Therapeutic Regimen, Efective: Individual Related to: Physiological and psychological chal- lenges of labor. Defining Characteristics: Client states (specifjr: e. g., “I can handle this now; I think I'll switch to the other breathing). Client uses breathing/relax-ation techniques (specifjr others) effectively during labor. Goal: Client will continue to be able to effectively manage her labor by (date/time to evaluate). Outcome Criteria Client adapts breathing techniques as labor pro- gresses (specifjr). Client is able to relax during and INTERVENTIONS RATIONALES Praise client's efforts to cope with labor contrac- tions and significant other's coaching ability throughout labor and birth. Inform client and signifi- cant other of labor progress and what changes to expect before they occur. Provide approximate time frames (e. g., transi- tion will probably last < an hour for a multipara). Suggest alternative coping techniques if client is hav- ing difficulty (specify: e. g., changes in position, breathing pattern, focus poindkeep eyes open, pres- sure over sacrum, music, massage, cool wash cloth, birthing ball, whirlpool, etc. ). Remind client to relax during and between con- tractions. Assist significant other to evaluate degree of client's relaxation. Role model coaching and support during contrac- tions if needed, then Praise reinforces client's belief in her ability to manage labor and birth, and significant other's coaching ability. Information and anticipa- tory guidance help client and significant other to feel some control over events. Transition is the most difficult part of labor. Client and significant other may benefit from alternative methods of coping with the discomfort of labor. Relaxation saves energy and decreases the fear-ten- sion-pain cycle by decreas- ing tension. Role modeling shows sig- nificant other how to help the client. Significant | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 93 INTERVENTIONS RATIONALES encourage significant other to take over role. Reassure client that if she feels she needs pain med- ication that she can still participate actively in the birth of her baby. Inform client when she is close to second stage. Provide constant support to client and significant other during the contrac- tions of transition and sec- ond stage. Encourage client to begin bearing-down efforts when she feels the urge to push. Instruct client to bear down at the peak of the contraction for no more than 6 seconds at a time and to exhale or make noise if she wishes. Encourage client to change positions frequently during second stage (e. g., sitting in chair, on birthing ball, squatting, walking, hands and knees, etc. ). Show significant other the fetal head as it comes into view. Allow client to wear a glove and touch the baby's head as desired. Offer praise to client and significant other for their good work after the birth. other may feel over- whelmed by the compe- tence of staff and need encouragement to partici- pate. Reassures the client that she is not a failure if she needs pharmacological help to cope with the dis- comfort of labor. Information allows client to evaluate what is hap- pening. Client and signifi- cant other may need extra support to hande the intensity of transition and second stage. Maternal efforts are more effective when the fetus has descended far enough to initiate Ferguson's reflex. Physiologic management of second stage causes less stress to the fetus than sus- tained maternal breath holding. Position changes facilitate descent of the fetus and empower the client to be in control of her birthing. Seeing or touching the baby's head reinforces maternal efforts to give birth. Praise reinforces family's bonding and positive memories of their birth experience. between contractions (other specifics as appropri- ate). Evaluation (Datehime of evaluation of goal) (Has god been met? not met? partially met?) (Did client adapt breathing techniques as labor progressed? Specify) (Was client able to relax during and between con- tractions?) (Revisions to care plan? D/C care plan? Continue care plan?) Injury, Risk for: Maternal and Fetal Related to: Dystocia, cephalopelvic disproportion, fetal malposition or presentation, precipitous birth, etc. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client and her infant will not experience any injury during labor and birth (evaluate after birth). Outcome Criteria Client's labor progress will be within the normal pattern on a labor curve. The fetus will descend at > 1 cm/hr during second stage. INTERVENTIONS RATIONALES Review prenatal record for pelvic measurement, length of previous labors, and size of infant. Review provides informa- tion about the passageway and pelvic adequacy,I 'd en- tifies clients at risk for pre- cipitous births or dystocia. Assessment provides infor- mation about the fetus as Assess fed lie, presenta- tion, and attitude using Leopold's maneuvers. passenger. Inform caregiver of abnor- malities. Perform baseline vaginal exam; repeat only as need-Assessment provides infor- mation about progress of | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
94 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES ed to determine progress. Assess presentation, posi- tion, station, membrane status and effacement and dilatation of the cervix during vaginal exams. Document progress on a labor curve. Assess contraction frequen- cy, duration, intensity, and uterine resting tone q 30” during active labor (q 15” if high risk), and q 15” during second stage (q 5” if high risk). Palpate con- tractions if external EFM is being used. If IUPC is used, document intensity in mm Hg. Assess fetal well-being on same schedule as contrac- tions by auscultation or EFM. Assess and docu- ment baseline FHR, vari- ability, and periodic and nonperiodic changes according to agency proto- col. labor, fetal position, and descent. Use of a labor curve allows comparison with the normal patterns for primiparas or multi- paras. Assessment provides infor- mation about contraction and adequacy of uterine resting tone. External EFM does not provide information on intensity. Contraction intensity with IUPC is measured in mm Hg: 30-40 = mild, 50- 60 = moderate, 70-SO = strong. Assessment provides infor- mation about fetal oxy- genation, and adequacy of oxygen reserves during contractions. Encourage client to change position frequently during labor: walk, sit on birthing ball, in rocking chair, etc. Notify care giver of non- reassuring FHR and insti- tute independent nursing measures as appropriate: decrease or discontinue oxytocin if infusing, initi- ate maternal position changes, give oxygen at 8- 12 L/min via face mask, f IV fluids, perform vaginal exam, etc. Position changes may facil- itate feral descent through the pelvis. Independent nursing mea- sures are designed to improve fetal oxygenation by decreasing uterine con- tractions, relieving cord compression, providing supplemental oxygen, increasing perfusion, and identifying factors that may be causing the dis- tress. Notify care giver if client is not making expected labor progress (e. g., dilatation of > Icm/hr in active labor, descent of z Icm/hr in 2nd stage. Keep client and significant other informed of labor progress and fetal well- being. If infant experiences shoul- der dystocia at birth, assist caregiver in applying Mc Roberts maneuver: flex mother's thighs onto abdomen, apply suprapu- bic pressure to rotate shoulder under symphysis. Timely notification alerts care giver to possible dys- tocia, need for augmenta- tion with oxytocin, or a reevaluation of pelvic ade- quacy. Information allows client and significant other to anticipate what will hap- pen and to participate in decisions. Shoulder dystocia occurs after the head delivers, when the anterior fetal shoulder becomes lodged behind the symphysis pubis. Mc Robert's maneu- ver widens the angle of the pelvic outlet. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) was client's labor progress within the normal labor curve?) (Did the fetus descend at > 1 cm/hr during sec- ond stage?) (Revisions to care plan? D/C care plan? Continue care plan?) Infiction, Risk fir: Maternal/Fetal Related to: Invasive procedures and ruptured membranes during labor and birth. Defining Characteristics: None, since this is a potential diagnosis. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 95 God: Client and fetus will not experience infec- tion from invasive procedures used during labor and birth by (datehime to evaluate). Outcome Criteria Client's temperature will remain c 100°F; new- born's temp will be < 98. 9"E ~-~ INTERVENTIONS RATIONALES Assess maternal tempera- ture q 4h until membranes rupture, then q 2h until birth. Assess maternal pulse and FHR baseline according to protocol for stage of labor. Assess amniotic fluid for color and odor during each vaginal exam. Limit vagi- nal exams. Assess any invasive devices (e. g., catheter, IV, continu- ous epidural) for sls of infection: redness, edema, discomfort, warmth, etc. q 4h or as indicated. Maintain medical asepsis by frequent hand washing; use clean gloves when in contact with body fluids. Use sterile technique per agency protocol for inva- sive procedures: e. g., IV therapy, vaginal exams, placement of a spiral elec- trode, AROM, catheteriza- tion, etc. Change under-buttocks pads frequently (at least q Assessment provides infor- mation about inflammato- ry processes. Maternal and fetal tachy- cardia may indicate infec- tion. Foul-smelling or thick, cloudy amniotic fluid may indicate chorioamnionitis. Bacteria may be intro- duced during vaginal exams. Systematic assessment pro- vides information about inflammation and infec- tious processes allowing early treatment. Frequent hand washing prevents the spread of pathogens; clean gloves protect the caregiver from pathogens. Sterile technique prevents the introduction of microorganisms into sterile areas of the body. Interventions promote cleanliness and avoid a INTEKVENTIONS RATIONALES 2h) to keep dient dry. Keep epidural dressing dry. Provide perineal care as needed, cleaning from front to back. Maintain a clean environ- ment: ensure that house- keeping has cleaned the room (OR), equipment, and bathroom (whirlpool); empty trash as needed. Avoid sharing equipment with other clients or other units in the hospital. Encourage client to void q 2h during labor. Provide privacy, run water, etc. to stimulate urination. Teach s/s of UTI to report: fre- quency, urgency, burning. Wash perineum prior to vaginal birth per hospital protocol using sterile tech- nique. Wash from front to back using a new sponge for each wipe-clean labia first and wash over the vagina last. For cesarean birth, per- form abdominal scrub and shave-prep per agency pro- tocol, remove scalp elec- trode, assist with mainte- nance of sterile technique during the surgery. After the placenta has delivered and any suturing is completed, apply a ster- ile perineal pad (ice pack if moist dark environment where bacteria may multi- ply. Front-to-back cleans- ing prevents fecal contami- nation of vagina/urethra. Cleaning prevents the spread of nosocomial infections within the hos- pital. Equipment should be des- ignated for obstetrics only to prevent cross-contami- nation. Urinary stasis during preg- nancy provides an opti- mum environment for bacterial growth. Voiding frequently avoids the need for catheterization. Teaching allows early iden- tification of a UTI. Cleaning the perineum J the number of microor- ganisms that may invade the vagina or lacerations during birth. Interventions J the num- ber of microorganisms that may be introduced into the abdominal cavity and uterus during surgery. Sterile peri pad prevents the introduction of microorganisms to the vagina, episiotomy, or lac- | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
96 MATERNAL-INFANT NURSING CARE PLANS ~~ ~ INTERVENTIONS RATIONALES indicated) front to back without touching the inner surface. Teach client how to apply peri pads. For cesarean birth, observe and maintain the sterile abdominal dressing. Wear clean gloves to pro- vide immediate care to the newborn and until after the first bath. Assess infant's temperature, pulse, and respirations at birth. Note how long membranes have been rup- tured. Administer newborn eye prophylaxis as ordered (specify medication & dose). Cleanse eyes first. If removing epidural catheter per anesthesia order, note that entire catheter is withdrawn, assess puncture site for redness, edema, and drainage. Apply a Band- Aid. erations. Ice, C edema. Application avoids fecal contamination. A wet dressing provides a medium for microorgan- ism growth. Clean gloves protect the caregiver from blood- borne pathogens. Assessment provides infor- mation about possible sep- sis (tachycardia, tachyp- nea). Prolonged rupture of membranes prior to birth increases the risk for infec- tion. Eye prophylaxis prevents neonatal ophthalmic infec- tions (specify action of drug that is used). Interventions rule out any retained fragments of catheter; local signs of inflammation or infection, a Band-Aid protects punc- ture site. Monitor lab results for signs of infection. Notify caregiver if s/s of infection develop in client or infant. Monitoring lab work allows early identification and treatment of infec- tions. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What is client's temperature? What is newborn's temperature?) (Revisions to care plan? D/C care plan? Continue care plan?) Fluid Blume Deficit, Risk for Related to: 4 p. 0. intake, 9 losses. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client will not experience a fluid volume deficit by (datehime to evaluate). Outcome Criteria Client will maintain urine output of 30 cc/hr or greater, mucous membranes will remain moist, B/P 2 (specify for client). Assess client hx for risk factors for hemorrhage (specify: e. g., overdistend- ed uterus, clotting prob-hemorrhage. lems, etc. ). Assess client's B/P, P, & R (specify frequency). Assessment provides infor- mation about client's propensity for perinatal Hypovolemia results in 4 BE'; the body compensates by vasoconstriction and f' I? C volume leads to hypoxia and 9 R. Assess intake and output every hour during labor and recovery. Assessment provides infor- mation about fluid bal- ance. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 97 INTERVENTIONS RATIONALES ~ ~~ INTERm ONS RATIONALES Assess skin color, temp, turgor, and moisture of lipslmucous membranes (specifj. frequency). Encourage p. 0. fluid intake (specify: type & amounts) during labor if allowed. Initiate and maintain IV fluids and/or blood prod- ucts as ordered (specify fluids and rate). Monitor lab results as obtained (specify: e. g., Hgb, Hct, urine sp. gravi- ty, clotting studies, etc. ). Monitor vaginal losses: bloody show and amniotic fluid. Notify care giver of excessive bloody show or if fetus develops severe vari- able decelerations. Note any unusual bleeding (e. g., from injection sites, gums, epistaxis, petichiae) and inform caregiver. After delivery of the pla- centa, assess uterine posi- tion, tone and color and amount of lochia; observe for hematomas and note integrity of incisions (spec- ify frequency). Encourage frequent emp- tying of the bladder after birch (catheterize as need- ed). Massage the uterus if boggy, guarding over the Symphysis. Administer Pale, cool skin, poor skin turgor, and dry lips or membranes may indicate fluid lossldehydration. Oral fluid intake promotes fluid replacement for insensible losses during labor. Provides replacement of fluid and/or blood losses. Changes in Hgb and Hct indicate the extent of blood loss. 9 sp. gravity may indicate fluid loss. Clotting studies indicate the client at T risk for hemorrhage. Monitoring provides infor- mation about abnormal blood loss: possible placen- tal abruption, or need for amnioinfusion to prevent fetal cord compression. Abnormal bleeding may indicate a clotting abnor- mality. Assessments provide infor- mation about uterine dis- placement and tone; vagi- nal blood loss, hidden bleeding, and wound dehiscence. Bladder distension may inhibit uterine contraction leading to excessive bleed- ing. Massage stimulates uterine tone (over-stimula- tion may cause relaxation), oxytocics as ordered (speci- 6: drug, dose, route, time). Estimate blood loss by counting or weighing peri- pads. Soaked pad in 15 rnin is excessive. (1 gm = 1 cc if weighing pads). Notify caregiver if bleeding continues after nursing interventions. (specify action of drug ordered). The degree of blood loss may not be apparent from appearance of vaginal dis- charge. Estimation helps determine replacement requirements. Continued blood loss may indicate retained placental fragments or a cervical lac- eration. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What is client's urine output? Is it 30 cdhr or greater? Are mucous membranes moist? What is client's B/P? Is it 2 (specify for client)?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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INTRAPARTUM 99 Basic Care Plan: Cesarean Birth Clients may be scheduled for a cesarean birth for several reasons including pelvic contracture, abnormal fetal presentation (e. g., transverse lie, breech), complete placenta previa, active genital herpes, or a previous cesarean with a classical uter- ine incision. Complications that arise during labor that may lead to cesarean birth include prolapsed cord, fetal distress, failure to progress, and cephalopelvic dis- proportion (CPD). Nursing Care Plans Infiction, Risk for: Maternah'Fetal(94) Related to: Site for organism invasion secondary to surgery. Fluid blume De Jicit, Risk for (96) Related to: Excessive losses secondary to wound drainage. Additi Sonal Diagnoses and Care Plans Anxiev Related to: Threat to biologic integrity secondary to invasive procedure and concern for fetal well- being. Defining Characteristics: Client states (specify using quotes: e. g., “I'm nervous; frightened; tense” etc. ). Client is trembling, crying; has 'P pulse, 'P BIP (specify other physiologic signs of anxiety). Goal: Client will cope effectively with anxiety by (datehime to evaluate). Outcome Criteria Client reports J( anxiety; pulse and B/P are with- in normal limits (specify for client); client appears calmer: is no longer crying, not trembling. INTERVENTIONS RATIONALES Assess client for physical and emotional signs of anxiety: trembling, crying, tachycardia, hypertension, dry mouth, or nausea. Acknowledge client's anxi- ety. Provide information about fetal status, realistic reassurance and support: stay with client, speak slowly and calmly, use touch as indicated (note cultural variance in use of touch). Explain all procedures and equipment on a level client can understand. Provide information about expect- ed neonatal care. Repeat information as needed. Include significant other in teaching and support. Encourage a support per- son to participate in cesarean birth if appropri- ate. Teach c:oping mechanisms (spec@ e. g.. relaxation & breathing techniques, visu- alization, etc. ) to client and significant other. If client is to have cesare- an, teach about what will happen during and after the birth, frequent v/s, need to turn, cough, deep..... Assessment provides infor- mation about emotional and sympathetic nervous system response to per- ceived threat. Acknowledgment validates client's feelings. Reassurance and support help the client to regain control. Personal space requirements and tolerance for touch varies with indi- viduals and cultures. High anxiety may interfere with concentration and ability to process informa- tion. Understanding decreases anxiety about unfamiliar experiences. Significant other may also be anxious about surgical interventions. Presence of a support person decreases client's anxiety. Effective coping helps the client and significant other to increase feelings of self- control during stressful experience. Preoperative teaching pro- vides anticipatory guidance about the post-operative interventions and how client can help herself. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
100 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES breathe, incision pain and relief methods available (specify: e. g., epidural morphine, PCA pump, IM narcotics, splinting inci- sion with pillow, etc. ). Introduce client and signif- icant other to members of the surgical and neonatal team if appropriate and explain their roles in the birth. If client is to have general anesthesia, describe sensa- tions she may feel, remain by her side and hold her hand until she is asleep. Describe sensations the client may feel if having epidural anesthesia: pres- sure, pulling and tugging, etc. Describe what is happen- ing during surgery andlor neonatal resuscitation. Ensure that client can see and touch infant before transfer. Arrange to visit the client on the 1st or 2nd postpar- tum day to review the birth and answer any ques- tions. Praise client and signifi- cant other for their effec- tive coping skills after the birth. Knowledge of pain relief measures helps 4 anxiety about pain. Introductions validate the client's individuality and worth. Anticipatory guidance enhances the client's ability to cope when new sensa- tions are felt. Touch may be especially reassuring at this time. Anticipatory guidance enhances the client's ability to cope when new sensa- tions are felt. Information decreases anx- iety about unfamiliar scenes and sensations. Intervention promotes attachment and 4 anxiety about newborn. Review and discussion assists the client to form an accurate impression of her birth experience. Praise may reinforce posi- tive coping skills in the hture. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client report 4 anxiety? What is pulse and B/P? Does client appear calmer? e. g., no longer crying, not trembling?) (Revisions to care plan? D/C care plan? Continue care plan?) Paii Z Related to: Tissue trauma secondary to abdominal surgery, post-delivery uterine contractions. Defining Characteristics: Client reports pain (specify degree using a scale of 1 to 10 with one being least, 10 being most), facial grimace, crying, guarding of incision, etc. (specify). Goal: Client will experience a decrease in pain by (datehime to evaluate). Outcome Criteria Client reports decreased pain (specify depending on what was reported first: e. g., < 5 on a scale of 1 to 10). Client is relaxed, not grimacing or crying, appropriate guarding of incision. INTER~NTIONS RATIONALES Assess location and charac- ter of pain when the client reports discomfort. Assess for cultural variations in pain response if indicated (e. g., Asian client may smile and deny any pain even with abdominal surgery). Assessment provides infor- mation about the cause of pain: may be incisional, uterine, or may indicate a complication such as hematoma. Different cul- tures have varied accepted responses to pain, which may differ from the nurse's. Assess client's perception of pain intensity using a Assessment provides quan- titative information about | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
TNTRAP~TUM 101 INTERVENTIONS RATIONALES scale of 1 to 10 with 1 being the least and 10 being the most pain. Administer appropriate pain medication as ordered (spec;@ drug, dose, route, times. Instruct pt in PCA pump use if indicated). Assess client for pain relief (specify timing for particu- lar drug given). Observe for adverse effects (specify for drug: e. g., itching, uri- nary retention with epidural morphine). Keep narcotic ~ragonist (naloxone) available if client has received narcotic analgesia. Assist client to change positions, encourage ambulation as soon as pos- sible. Provide a comfort- able environment (temper- ature, lighting, etc. ). Teach client to ask for pain medication before pain becomes severe or before planned activity. Teach client nonpharma- cological interventions: (specify: e. g., splinting incision with pillow, rolling to side before rising from bed, etc. ). Offer nonpharmaco~ogical pain interventions if desired: e. g., therapeutic touch, back rub, music, etc. client's perception of pain and guides the choice of medications. Level of pain is what the client says it is. (Specify rationale for choosing the drug: eg., is drug contraindicated if breast feeding? Describe action of specific drug. ) Assessment provides infor- mation about client's response to medication. Ndoxone reverses the effects of narcotics in cases of overdose. Position changes decrease muscle tension, ambula- tion decreases flatus, com- fortable environment enhances relaxation. Pain medication is more effective and less is needed if given before pain is severe. Premedication affords pain relief for activ- ity. (Specify rationale: e. g., splinting and rolling to the side prevents traction on the incision site. ) INTERS'EN"I0NS RATIONALES Teach client about the physiology of after-pains (relate I:O breast-feeding as indicated). with after-pains. Noti6 caregiver if pain is not controlled or if com- plications are suspected. Understanding the physi- ology may 6 anxiety and pain perception associated Caregiver may order a dif- ferent analgesic or decide to re-evaluate the client. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What degree of pain does client report? Is client calm? relaxed? not grimacing, etc? Describe client's activity. ) (Revisions to care plan? D/C care plan? Continue care plan?) Positioning Injury (Perioperative), Risk for Related to: Positioning and loss of normal sensory protective responses secondary to anesthesia. Defming Characteristics: None, since this is a potential diagnosis. Goal: Client will not experience any positioning injury for duration of anesthesia. Outcome Criteria Client's B/P remains 2 (specify for client). Client denies any leg or back pain after anesthesia wears Off. I"T0NS RATIONALES Nonp~~macologic~ inter- ventions may use distrac- tion or the gate-control theory to 4 pain percep- tion. Assess client for any previ- ous back or leg injuries or conditions that may be affected by surgical posi- tion. Assessment provides infor- mation about pre-existing risk factors for periopera- tive injury. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
102 MATERNALINFANT NURSING CARE PLANS INTEIWENTIONS RATIONALES Assist with positioning for epidural anesthesia as needed. If client has epidural anes- thesia, protect her legs from possible falls or tor- sion injury-SR 'b ?, guard legs if knees are raised to insert foley, etc. Position client supine on the operating table with a wedge under her right hip and a pillow under her head. Apply safety straps. Align spine and neck at all times. Tilt the table to the left as ordered. Evaluate fetal heart rate prior to abdominal scrub and draping. Ensure that client's legs are in a natural, aligned posi- tion without crossed ankles before draping (inform client not to cross ankles if preparing for general anes- thesia). Assist anesthesia provider with natural posi- tioning of client's arms at side or on arm board Use padding for bony prominences (e. g., pad arm boards, heels, etc. ). After surgery is complited, move client to a stretcher using a roller and draw sheet and enough staff to maintain client's body alignment during move. Assess client's skin condi- tion as she is being cleaned Proper positioning facili- tates introduction of the epidural catheter and avoids client injury. Interventions protect the client's legs from filling and hyperextending the hip joint. Safety strap prevents client falls. Alignment presents nerve injury. Tilting the uterus to the left facilitates maternal venous return and uteroplacental perh- sion. Assessment provides infor- mation about placental perhsion. Natural positioning pre- vents torsion and pro- longed mechanical pressure on nerves and circulatory system during surgery. Padding decreases pressure over bony areas, which can interfere with circulation. Maintaining alignment prevents torsion or twist- ing of the client's body. Providing adequate st& prevents staff injuries. Assessment provides infor- mation about possible tis-up after surgery. Note any reddened or blanched areas. Assess return of motor and sensory hnction in legs as epidural wears off. Maintain safety precau-again. tions (side rails up, etc. ) until client has full use of extremities. Notitjl caregiver and anes- thesia provider of any unusual findings or com-injury. plaints. sue injury. Assessment provides infor- mation about when client may safely use her legs Notification allows care- giver to investigate possible Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did client's B/P remain 2 (what was specified for client)? Does client deny any leg or back pain afier anesthesia has worn off?) (Revisions to care plan? D/C care plan? Continue care plan?) Partw-hfint Attachment, Risk for Altered Related to: Barriers to or interruption of attach- ment process secondary to surgical routine or ill- ness of motherhnfant. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client will demonstrate appropriate attach- ment behaviors by (date/time to evaluate). Outcome Criteria Parents will hold infant following birth. Parents and infint will make eye contact. Parents will verbalize positive feelings towards infant. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 103 INTERVENTIONS RATIONALES Assess maternal feelings towards the fetus prior to birth: e. g., “DO you have a name chosen?” Note non- verbal cues. Inform parents of fetal responses as assessed by FHR prior to birth. Assess cultural expectations of the parents and their families related to mother- baby care after birth. Solicit information about dietary needs, and who is expected to care for the infant. Share information with all staff. Provide parents with an opportunity to see and touch the baby immediate- ly after birth. If infant needs resuscitation, allow parents to see and touch infant prior to transfer to nursery. Delay eye prophylaxis and other unnecessary proce- dures until parents have had an opportunity to hold infant for 30 minutes to 2 hours per protocol. For cesarean births with general anesthesia, allow the father (or significant other) to be present after induction to bond with the infant. For cesarean births, take infant to recovery room with mother and encour- age her to hold and breast feed infant if desired. Assessment provides infor- mation about prenatal attachment to the fetus. Information helps the par- ents view fetus as a real baby. Assessment provides infor- mation about cultural vari- ations: e. g., in some cul- tures the mother is expect- ed to rest while others care for the infant. Cold foods may be prohibited during the puerperium. Mothers and infants are ready to form attachment in the first few minutes after birth. If the infant is ill, seeing and touching the baby reduces parental anxi- ety and fosters attachment. Eye prophylaxsis may interfere with the infant's ability to see his parents' faces. The first period of sensitivity lasts 30-90 minutes. Allowing father to be pre- sent fosters parent-infant attachment even if mother is asleep. Post-operative clients, who are not too sedated, are able to interact with their baby just as vaginal birth mothers do. INTERVENTIONS RATIONALES For vaginal births, keep the infant with the par- ents. Teach parents about assessments and interven- tions as they are per- formed. Administer pain medica- tions to the mother as needed (specify). Encourage and facilitate breast-feeding immediately after birth if indicated. Encourage parents to hold their baby skin-to-skin (kangaroo care). Promote bonding by pointing out attractive fea- tures of the infant and his response to the parents. Praise parental care-giving skills as indicated. Assess attachment behav- iors of parents: eye con- tact, touch, and verbaliza- tion about the baby, Share observations with caregiver and postpartum staff. If infant is ill and taken to nursery, take parents to see infant as soon as client is stable. Encourage parents to participate in caring for infant in the nursery as possible. Attachment requires prox- imity. Involvement in assessments and interven- tions facilitates the begin- ning of parenting skills. Pain may distract the client from attachment and bonding with her infant. Early breast-feeding pro- vides lactose for the infant after the stress of labor; nipple stimulation causes a release of oxytocin for the mother: f' uterine con- traction and C vaginal bleeding. Skin-to-skin positioning provides warmth for the infant and facilitates attachment. Intervention helps parents adjust their idealized thoughts about the baby with the real baby. Parenting is a learned process. Praise promotes self-esteem. Failure to make eye con- tact, avoidance of touch, or negative expressions may indicate attachment problems, which need to be evaluated further. Interventions foster attach- ment and reduce parental anxiety. If infant is very ill, parents may be afraid to touch or care for their baby. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
104 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES If infant is transferred to another facility, provide parents with photos and mementos of the infant before transport and the phone number of the facil- ity. If mother is too ill to care for infant, or if cultural prescriptions interfere with family members. infant care, encourage father or other family member to stay in room. Refer parents as needed (specify: e. g., social ser- vices, congenital anomaly support groups, grief sup- port, etc. ). cultural beliefs. Interventions promote attachment and informa- tion until the client is reunited with her infant. Family-centered care pro- motes attachment with all Intervention provides addi- tional assistance for par-ents having difficulty with attachment or supports Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Did parents hold infant following birth? Did par- ents and infant make eye contact? Did parents verbalize positive feelings towards infant? Specify using quotes. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
Induction & Augmentation- Induction refers to artificial stimulation of labor before it has spontaneous~y started. ~ugmentation is artificial stimulation to enhance labor after it has begun naturally. Reasons for induction include maternal and fetal conditions that prohibit continuing the pregnan- cy. These may include: severe PIH, fetal demise, IUGR, prolonged ruptured membranes, chorioamnionitis, diabetes mellitus or other severe maternal illnesses, and verified postterm pregnan- cy. Induction may be accomplished by use of cer- vical ripening agents if the cervix is unfavorable, followed by ~n~~tom~ and oxytocin infusion. Augmentation usual Iy consists of amniotomy andlor oxytocin infusion to increase the intensity and frequency of hypotonic uterine contractions. Contraindications to induction or augmentation are contraindications to labor contractions and vaginal birth. These include fed distress, com- plete placenta previa, active genital herpes, CPD, previous classical uterine incision, and fetal ma1 presentation. Care shodd be taken to verifj fetal gestational age prior to inducing labor. Medical Care Fetal maturity assessment: LNMP, serial ultra- sound me~urements, and possibly amniocente- sis for US rario Determination of fetal lie, presentation, and sta- tion Assessment of cervical readiness for labor: e~cement, dilatation, position, and consisten- cy (Bishop's scoring may be used) Cervical ripening agents (PGq gel, dynopras- tone, or misoprostof) may be used to soften the cervix prior to oxytocin induction AROM (artificial rupture of membranes) may stimulate contractions Con~~uous EFM; ~nt~venous oxytocin (P~toc~n~ pig~backed to a mainline IV via an in~sion pump; dilution of pitocin is per order. Pitocin is titrared to labor pattern and fetal tol- erance Nursing Care Plans Ildditional Diagnoses and Care Plans ~~~~~, ~~~~r~ ~~~e~~~~~~ Relad to: Effects of drugs used to induce or aug- ment labor. Defining Characteristics: None, since this is a potential diagnosis, God: Client and fetus will not experience any injury related to the use of drugs used to induce or augment labor by (dateltime to evaluate}. Outcome Criteria ~on~acuon frequency not less than q 2-3 min- utes, not more than 60 second duration, and ade- quate resting tone benveen contractions. FHR remains reassuring with no late decelerations. Obtain baseline maternal vls. Assess fetal presenta- tion, position, Station, and cervical &cement and dilatation. Position client ta I perfusion. on left side if tolerated. Assessment provides base- line data prior to induc- tion or augmentation. Position kcilitates placen- | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
106 MATERNAL-INFm T NURSING CARE PLANS INTERVENTIONS RATIONALES Apply EFM and obtain a 20-minute strip prior to beginning induction. Assess baseline FHR, vari- ability, and periodic and nonperiodic changes. If FHR are nonreassuring, notify provider without starting oxytocin. Assess uterine activity by palpation or IUPC before starting induction. Explain induction or aug- mentation rationale and procedure to client and significant other before starting. Allow time for questions. If cervical ripening agent is to be used, follow agency protocol for IV access, placement, length of time to remain supine, and how long to wait before begin- ning oxytocin (speci@). If uterine hyperstimulation or nonreassuring FHT develop, remove the ripen- ing agent, turn client to left side, provide humidi- fied oxygen at 8-12 Wmin via facemask, and notie physician. Administer a tocolytic as ordered, Start mainline IV as ordered by care provider (specie which fluids and rate) with an 18 gauge (or larger) catheter on non- dominant arm or hand, avoiding use of armboard. Assessment provides data about fetal well-being prior to beginning oxytocin. Increased intensity of con- tractions might be harmful to an already stressed fetus. Assessment provides base- line data about contrac- tions and resting tone. Contractions may be ade- quate without oxytocin. Explanation decreases client and significant other's anxiety about the procedure and reason for it. Cervical ripening prepara- tions have different requirements for place- ment and timing. Agency protocol may require a heparin lock or KVO Iv. Cervical ripening agents may cause uterine hyper- stimulation and decreased uteroplacental perfusion causing fetal hypoxia. Tocolytics decrease uterine activity. Mainline IV provides venous access should oxy- tocin need to be discontin- ued. 18 gauge or larger needle is indicated if client might need blood; place- ment allows client use of her hand. INTERVENTIONS RATIONALES MU oxytocin in N solu- tion as ordered by care provider (specie fluid type, amount, and how many units of oxytocin). Thread oxytocin IV tubing through an infusion pump. Piggyback oxytocin to mainline IV at a distal port. Begin inhsion as ordered (specify: e. g., 0. 5 m U/min or 1 m U/min). Assess maternal B/P, P, R, and assess fetal baseline heart rate, variability, peri- odic, and nonperiodic changes q 30 min or before increasing oxytocin infusion rate. Assess uterine contractions for frequency, duration, intensity, and resting tone by palpation or IUPC q 15-30 min or before increasing oxytocin. Titrate oxytocin as ordered to obtain contractions q 2- 3 min, of 60 second dura- tion, and moderate inten- sity with adequate resting tone. Once active labor is established, the oxytocin dose may be decreased. Decrease or discontinue oxytocin if contractions are closer than q 2 min or last Oxytocin has an antidi- uretic effect by causing retention of free water. Caregiver may choose an electrolyte fluid (rather than dextrose and water) to 4 this effect. Dilution determines the volume for each milliunit (mu). Pump ensures correct dosage is given. Piggybacking the drug maintains IV access if oxy- tocin needs to be discon- tinued. Using a distal port allows oxytocin to be dis- continued without addi- tional drug inhsing through excess tubing. Assessment provides infor- mation about complica- tions of oxytocin: fluid excess, ruptured uterus, fetal distress. Assessment provides infor- mation about effects of oxytocin needed for titra- tion of the drug. Most clients will have ade- quate contractions with 10 m U/min or less of pitocin. Uterine hyperstimulation may result in 4 placental perfusion causing fetal hypoxia or uterine rupture. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 107 INTERm ONS RATIONALES Evaluation (Date/time of evaluation of goal) 90 seconds or there is an 9 in resting tone (> 20 mm Hg with IUPC). Observe client for unusual discomfort. Notify physician if hyper- tonus continues after oxy- tocin has been discontin- ued. Administer tocolytics as ordered (spec$, drug, dose, and route). Discontinue oxytocin if a nonreassuring fetal heart rate pattern develops. Position client on her left side, increase mainline IVF, provide humidified oxygen at 8-12 Umin via facemask. Notify physician of fetal heart rate pattern, actions taken, and result. Document notification. Encourage client to void q 2h. Monitor hourly intake and output. Perform sterile vaginal exams as needed to moni- tor progress of labor. Keep cfienr and significant other informed of labor progress and any changes in the plan of care. Oxytocin has a short half- life (3-5 min). Continued hypertonus may indicate the need for tocolytics to relax the uterus and increase placental perfit- sion. (Action of drug. ) Oxytocin may cause uter- ine hyperstimulation or increased resting tone, which interferes with pla- cental perfusion. Interventions increase pla- cental perhion and oxy- gen availabfe to the fetus. Oxytocin has a slight antidiuretic effect. Interventions prevent blad- der distention and pro- vides information about fluid balance. Vaginal exams provide information about effec- tiveness of induction or augmentation. Informat~on promotes understanding and decreases anxiety, which may slow labor progress, (Has goal been met? not met? partially met?) (Describe contraction frequency, duration, and intensity and uterine resting tone. Describe base- line FHR, variability, periodic and nonperiodic changes. } (Revisions to care plan? D/C care plan? Continue care plan?} Fluid Volume Excess, Risk for Related to: Water intoxication secondary to anti- diuretic effect of oxytocin and administration of intravenous fluids. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client will not experience fluid volume excess, Outcome Criteria Client. 's urine output is > 30 cclhr. Client does not experience altered level of con- sciousness, or convulsions. 1"IWWENTIONS RATIONALES ~ Monitor hourly intake and output while oxytocin is inhsing. Observe client for signs of water intoxication includ- ing subtle changes in men- tal status, confusion, lethargy, nausea, andior convu Isions. Discontinue oxytocin and JI mainline to WO; notify physician. Monitor lab values as obtained. Urine output may 4 as oxytocin causes the kid- neys to reabsorb free water. Oxytocin dosage > 20 m Ulmin is associated with 4 urine output. Excessive retention of free water causes a ~yponatremic, hypoosmotic state, result- ing in cerebral edema. Serum sodium < 120 m Eql L or plasma osmolal- ity I 240 m Osm/kg indi- | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
10s MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Collaborate with caregiver to mix oxytocin in an elec- trolyte solution rather than dextrose and water. When oxytocin needs to be inhsed at > 20 m U/min for several hours, increase the strength of the infusion rather than the volume (e. g., mix 10 U oxytocin in 500 cc fluid so that 3 cc/hr=I m U/min or 10 U oxytocin in 250 cc fluid so that 1. 5 cdhr = 1 m U/min). Assess mainline IV rate each hour. As oxytocin infusion is increased, decrease mainline IV rate to provide IVF at ordered rate (specify: e. g., 125 cc/hr). If labor is not established after 8 hours, collaborate with caregiver to discon- tinue the infusion until the next day. Evaluation cate immanent water intoxication. With large doses of oxy- tocin, the risk of water intoxication is greater if oxytocin is mixed with electrolyte-free water and dextrose. Strengthening the solution decreases the volume that needs to infuse. Mainline may be periodi- cally opened up for mater- nal hypotension or fetal distress. Intervention avoids infusing large amounts of fluid as oxy- tocin is increased. Intervention promotes client rest and decreases the risk of water intoxica- tion from high doses of oxytocin. (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What is urine output? Is client's level of con- sciousness appropriate? Has client had any convul- sions?) (Revisions to care plan? D/C care plan? Continue care plan?) Gas Excbang, Impaired Risk fir: Fetal Related to: Cord compression secondary to AROM and prolapse of the umbilical cord. Defining Characteristics: None, since this is a potential diagnosis. Goal: Fetus will not experience impaired gas exchange after AROM. Outcome Criteria FHT remain reassuring (specify) after AROM. Prolapsed cord is not palpated on vaginal exam after AROM. ~ INTERVENTIONS RATIONALES Assess baseline FHR before membranes are ruptured. Note variability and pres- ence of accelerations or decelerations. Explain AROM procedure to client including expect- ed benefits and sensations she may feel (warm, wet, no pain, possible f con- tractions). Encourage client to breathe deeply and relax during procedure. Assess fetal presentation, position and station prior to AROM. Notify caregiv- er of findings. Position client on chux or pads and assist caregiver to perform AROM by open- ing amnihook and apply- ing gentle hndal pressure if requested. Assessment provides infor- mation about individual fetal baseline heart rate and well-being. Explanation decreases anx- iety about procedure and ensures client understand- ing and cooperation. Client relaxation facilitates vaginal exam and amnioto- my. Fetus should be cephalic or frank breech and well- engaged with presenting part against the cervix to prevent prolapsed cord. Dry pads will absorb excess fluid. Light fundal pressure may be needed to expel fluid and move the presenting part against the cervix to prevent prolapsed cord. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTWARTUM 109 If RN is to perform AROM, obtain order, ensure that presenting part is cephalic and well- engaged against the cervix. If not, notify caregiver of findings and do not per- form AROM. Perform procedure according to agency protocol. Palpate for a prolapsed cord after fluid has escaped. Assess FHR immediately after amniotomy and through the next few con- tractions. Note date and time of AROM on EFM strip and in chart. Observe color, amount, and odor of amniotic fluid at time of AROM and during each subsequent vaginal exam. Provide a dry chux or pad after AROM. Change pads frequently throughout duration of labor. Assess client's temp q 2h after membranes have 'up- tured until birth. If nonreassuring variable decelerations develop, change maternal position, provide oxygen at 8-12 L/min via facemask, and perform vaginal exam to Many boards of nursing do not allow staff nurses to perform AROM or may require extra competency instruction and certifica- tion. The RN is responsi- ble for knowing what the state board defines as the scope of practice, and per- forming the procedure safely. Assessment provides infor- mation about fetal oxy- genation. Prolapsed cord may be obvious or occult. Documentation provides information about activi- ties affecting fetal condi- tion during labor. Assessments provide infor- mation about fetal well- being: rneconium indicates stress unless fetus is breech, blood may indicate abruption, an unpleasant odor may indicate infec- tion. Dry pads keep client com- fortable and decrease the warm, wet environment favored by microorgan- isms. Assessment provides infor- mation about possibie development of infection. Decreased amniotic fluid may cause cord compres- sion resulting in variable decelerations. Maternal position change may relieve the pressure on the cord. ~~~TIONS RATIONALES rule out prolapsed cord. Notify caregiver of severe variable decelerations, interventions, and fetal response. Provide for amnioinhsion as ordered per agency pro- tocol (speci~). on the cord. Prepare client for emer- gency cesarean if ordered for prolapsed cord or fetal distress. ~nioinfu~ion may be ini- tiated to reduce pressure Obstruction of fetal gas exchange may require emergency cesarean birth. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Is FHR reassuring? Describe FHT: baseline, vari- ability, periodic, and nonperiodic changes. Does vaginal exam rule out prolapsed cord after AROM?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
110 MATERNALINFANT NURSING CARE PLANS Induction & Augmentation Contractions Induction 1 cenrical readiness? /l J No Yes ' AROM 1 ce&cd ripening agents I oxytocin f-------l start at 1-2 mu/& Augmentation Po*& titrate o~ocin to labor pattern and fetal response start at 0. 5 m U/min 4 | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 111 Regional Analgesia Pain relief measures that affect a specific body area are termed regional analgesia or anesthesia. The drugs (usually local anesthetic and/or a narcotic analgesic) are injected near specific nerves. Local anesthetics interrupt the transmission of impulses for pain, motor, and sensory nerves. Narcotics bind to opioid receptors and decrease pain percep- tion only. Commonly used local anesthetics in obstetrics are lidocaine, bupivicaine hydrochlo- ride, and 2-chloroprocaine hydrochloride. Commonly used narcotics are fentanyl, sufentanil, and morphine. The most common regional anesthesia used in childbirth is local perineal infiltration for episioto- my. Another common usage in the United States is epidural analgesidanesthesia employed for labor pain and cesarean birth. Epidurals may employ local anesthetics alone or combined with nar- cotics. Intrathecal analgesia is injection of a nar- cotic into the subarachnoid space. This provides pain relief without motor, sympathetic, or sensory block. Other types of regional analgesia some- times used in childbirth include pudendal, and spinal blocks. Complications Epidural using local anesthetics: maternal hypotension from sympathetic block causing vasodilation and pooling of blood in the legs; may result in nonreassuring FHR pat- terns may interfere with labor pattern causing pro- longed labor; may lead to cesarean birth may block maternal urge to push; may be asso- ciated with increased use of forceps high block or complete block may result in res- piratory arrest post dural-puncture headaches systemic toxicity resulting in convulsions, car- diac depression, and dysrhythmias Epidural narcotics: respiratory depression urinary retention, bladder distension pruritis, nausea, and vomiting Medical Care Regional analgesia and anesthesia (excluding local infiltration) should be provided by a quali- fied, credentialed, licensed anesthesia care provider who injects the drugs, stabilizes the client, and is available to adjust dosage and treat complications Contraindications may include hypovolemia, coagulation defects or anticoagulant therapy, and local infection IV of a balanced salt solution (e. g., Ringer's Lactate) with a bolus of 500-1000 cc given prior to epidural placement to avoid hypoten- sion After aspiration to avoid injecting the drug into a blood vessel, a test dose is given to rule out sensitivity catheter may be placed for repeated or continu- ous epidural analgesia Drugs may be given by single injection or a Nursing Care Plans Infection, Risk fir (94) Related to: Site for organism invasion secondary to presence of epidural catheter. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
112 MATERNAL-INFANT NURSING CARE PLANS Positioning Injury (Perioperative), Risk for (101) Related to: Loss responses. Additional Pain (Acute) of usual sensory protective Diagnoses and Plans Related to: Uterine contractions and perineal stretching during labor, Defining Characteristics: Client reports pain (specify rating on a scale of 1 to 10 with 1 being least, 10 most) and requests pain relief measures (specify: e. g., “Can 1 have my epidural now?”). Client is grimacing, crying, etc. (specify). Goal: Client will experience a decrease in pain by (date/time to evaluate). Outcome Criteria Client will report a decrease in pain (specify: e,g., < 5 on a scale of 1 to 10). Client will not be cry- ing or grimacing (specify for individual response). INTERVENTIONS RAIITONALES Assess client for pain every hour during labor. Note verbal and nonverbal cues. Assess location and charac- ter. Ask client to rate pain on a scale from 1 to 10 with 1 being least, and 10 being the most pain. Accept the client's inter- pretation of pain and avoid cultural stereotyping. Explain the physiology of the discomfort the client is experiencing (e. g., back labor and OP position, Assessment provides infor- mation about etiology of pain (e. g., contractions, perineal stretching, or uterine rupture. ) Rating allows objective quantita- tive reassessment. Pain is a personal experi- ence. The expression of pain is influenced by cul- tural norms. Explanations decrease fear of the unknown and assist the client to cope with dis- comfort. INTERVENTIONS RATIONALES cervical dilatation, pressure during descent). Reinforce client's use of breathing and relaxation techniques learned in childbirth classes. Support coaching from signi~~nt other. Assist client and significant other with suggestions and implementation of non- pharmacological pain relief measures if desired (speci- fy: e. g., position changes, back rub, massage, whirlpool, etc. ). Explain the medical pain relief options available to the client (specify: IV nar- cotics, epidural, inuathe- cal, etc. ). Briefly discuss advantages and disadvan- tages of each option. Administer systemic anal- gesia as ordered (specify: drug, dose, route, & time). Notify anesthesia care provider if client is to have regional analgesia. Monitor maternal and fetal response to medication; observe for adverse effects (specify for drug). Reevaluate client's percep- tion of pain afier drug has taken effect (specify time frame for drug given) using a scale of 1 to 10. Notify caregiver or anes- thesia provider if measures Support assists the client and significant other to use techniques learned in ~ildbirth education classes. Client may wish to have an unmedicated birth and only need support rather than drugs to cope with the discomfort of labor and birth. Information empowers the client to decide between the available options to meet her individual needs. (Specify action and side effects for each drug. ) Early notification pro- motes timely pain relief if anesthesia provider is not readily available. (Specifj. for drugs given: e. g., IV narcotics may cause 4 FHR variability. ) Timing of pain relief varies with different drugs and routes. Pain refief measures need to be individualized. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 113 INTERVENTIONS RATIONALES aren't effective in decreas- ing client's perception of pain. er dosage. Client may respond better to a different drug or high- Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What does client rate pain on a scale of 1 to 10, Is client crying or grimacing? Describe activity. ) (Revisions to care plan? D/C care plan? Continue care plan?) ~nj~~~~ Risk for: Mu~e~u~ and Fed Related to: Effects of drugs used for pain relief during labor and birth. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client and fetus will not experience any injury from medications used during labor by (date/time to evaluate). Outcome Criteria Client's B/P, P, R remain within normal limits (specify a range for client). FHT remain reassur- ing and newborn exhibits spontaneous respirations at birth. INTER~~ONS RATIONALES Assess client's baseline vital Assessment provides infor- signs before analgesia mation about individual administration. baseline to help identify any adverse drug effects. Assessment provides infor- mation about baseline fetal status to help identify any adverse drug effects. Assess fetal well-being (FHR, variability, accelera- tions, or decelerations) before providing analgesia. INTERVENTIONS Start an IV if ordered (specify fluid and rate: e. g., for epidural, give bolus of 500-1000 cc if ordered). Administer IV push anal- gesia slowly during a con- traction (specify: drug, dose, and time). Raise side rails, place call bell within reach and instruct client not to get out of bed after receiving narcotic or epidural anal- gesia. Reassess client's Bi P, P, and R and fetal well-being at expected peak of drug action (specify for drug). Time systemic narcotics to avoid respirato~ depres- sion in the newborn (spec- ify for individual drug). If client is to receive an epidural encourage the client to void before the procedure. Apply continuous EFM for clients receiving region- al analgesia. Document assessments of fetal well- being per agency protocol. Ensure that oxygen, suc- tion, and resuscitation drugs and equipment including bag and mask are readily available. Assist anesthesia care provider to provide epidur- al or intrathecal analgesia RATIONALES An IV provides venous access for hydration and treatment of complica- tions. Intervention prevents a large bolus of drug from crossing the placenta. Interventions promote safety by preventing rnater- nal falls while sedated. Assessment provides infor- mation about client's phys- iologic response to drug and fetal effects. Narcotics given to the mother should wear off before or peak after birth to avoid respiratory depres- sion in the newborn. Epidural analgesia may J the sensation of a full blad- der and the ability to void easily. Continuous EFM provides information about effects of analgesia on the fetus. Systemic effects of regional analgesia may result in life- threatening complications (respiratory arrest, cardiac dysrhy~mi~, etc. ). Assistance facilitates epidural placement. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
114 ~TE~~INF~T NURSING CARE PLANS INTERVENTIONS RATIONALES Evaluation by obtaining supplies and positioning client as indi- cated. Assess client for dizziness, slurred speech, numbness, tinnitus, or convulsions after epidural test dose is given. After dose is given, assist with repositioning client and assess maternal v/s and fetal status per protocol (speci Q: e. g., q 2” X 20)” etc,). If client develops hypoten- sion or nonreassuring FHT, position on left side, provide a bolus of IVF, and administer humidified oxygen at 8-12 Wmin. If improvement not noted, notifj. anesthesia provider, Assess bladder and encour- age voiding g 2h. Catheterize as ordered if bladder is distended and client is unable to void. Palpate contractions and assist client to push during second stage if needed. Assess and support new- born's respiratory effort at birth. Have neonatal naloxone and resuscitation equipment ready for all births. Ensure that entire epidural catheter is removed after delivery by noting mark on the tip. Assessment afier test dose provides early indications (Dateltime of evaluation of goal) (Has goal been met? not met? partially met?) (What are client's B/R I? and R? Did FHT remain reassuring? Did newborn exhibit spontaneous res- of central nervous system pirations?) toxicity. (Revisions to care plan? DIC care plan? Continue care plan?) Repositioning the client facilitates therapeutic effects of the epidural drugs. Epidurals may cause hypotension due to sympa- thetic block and pooling of blood in legs. Maternal hypotension decreases placental blood flow leading to late decef- erations. Interventions should 9 blood volume, oxygen saturation, and pla- cental flow. Interventions prevent blad- der distension, which may obstruct labor and result in bladder injury and infec- tion. Epidural may interfere with the urge to push dur- ing second stage. Labor analgesia may cause neonatal respiratory depression. Naloxone is a narcotic antagonist. Mark indicates entire catheter has been removed and hasn't broken off | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 115 Regional Analgesia local anesthetic narcotic agents local spinal block epidural block infiltration I I 1 1 vaginal birth vaginal or labor pain tissue repair cesarean vaginal or birth cesarean birth intrathecal analgesia 1 labor pain vaginal birth | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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INTRAPARTUM 117 Failure to Progress Failure to progress refers to labor dystocia with a lack of progressive cervical dilatation and or fetal descent. Systematic assessment of the “P's” of labor may help define the Cause. Evaluation of the powers may show that the contractions are too weak or uncoordinated. A discrepancy between fetal size or position (passenger) and the pelvis (passageway) may inhibit fetal descent. High maternal anxiety (psyche) and maternal position- ing may also interfere with labor progress. Evaluation of fetal size, presentation, position, and pelvic adequacy ated if uterine hypotonus is diagnosed and CPD ruled out Forceps or vacuum extraction may be tried if the problem develops in the second stage AROM or oxytocin augmentation may be initi- Cesarean delivery for CPD Nursing Care Plans Related to: Cephalopelvic disproportion, dystocia, prolonged labor, etc. Anxiety (97) Related to: Perceived threat to self or fetus sec- ondary to prolonged labor with lack of progress. Defining Characteristics: Client expresses feelings of helplessness and tension, expresses worry about fetal well-being (specify, using quotes). Client exhibits signs of anxiety (specify: e. g., crying, withdrawn, or angry and critical, etc. ). Additional Diagnoses and Plans Fatipe Related to: Increased energy expenditure and dis- couragement secondary to prolonged labor with- out progress. Defining Characteristics: (Specify length and pro- gression of client's labor. ) Client states (specify: e. g., I m so tired, I can't do this anymore”). Client is (specify: uncooperative, crying, lethargic, listless, irritable, etc. ). Goal: Client will experience a decrease in physical and mental fatigue by (dateltime to evaluate). Outcome Criteria Client verbalizes understanding of plan of care. Client rests between contractions. Client is coop- erative and not crying (specify other objective m~uremen~). (4 > INTERWNTIONS RATIONALES Allow client to express feelings of frustration and fatigue. Validate concerns. Provide physical and emo- tional support to client and significant others. Inform client and signifi- cant others about expected labor progress and realistic evaluation of client's labor pattern. Assess for the causes of failure to progress: powers, passenger, passageway, position, and psyche. Notify caregiver of lack of progress, client's fatigue and assessment findings. Interventions validate client's perceptions of the experience. Client may expend more energy being distressed. Family may also be tired. Client and family may have unrealistic expecta- rions about labor progress. Assessment provides infor- mation about possible causes and infers solutions to the problem of failure to progress. Information assists caregiv- er in determining a plan of care for client. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
118 MATERNALINFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Explain medical plan of care to client and signifi- cant other (specify: e. g., sedation, augmentation). Ensure hydration by pro- viding fluids as ordered. Suggest fruit juices (if cesarean is unlikely) or IV solutions with added dex- trose. Provide refreshments for significant other if desired. Provide a calm environ- ment; dim lights, JI vol- ume on monitor, ask extra visitors to leave. Assist client to conserve energy by resting between con- tractions, and accepting sedation if ordered. Instruct client in relaxation techniques and mental imagery. Offer soothing music, a back rub, or mas- sage as indicated. Encourage significant other to rest also. Provide pillows and blankets if needed. Keep client and significant other informed of labor progress, fetal status, and changes in plan of care. Evaluation Explanation helps dispel feelings of helplessness and hopelessness. Dehydration and starva- tion contribute to fatigue during labor. Significant other may neglect personal needs when focusing on client. Decreased environmental stimulation promotes rest. Client may feel that she is a failure if she accepts medication. Interventions promote conservation of energy and positive thoughts facilitat- ing mental and physical relaxation. Support person may also be fatigued and anxious, adding to client's distress. Information promotes a sense of trust and relax- ation. (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does client verbalize understanding of plan of care? Is client resting between contractions? Is client cooperative and not crying? Specify other objective criteria. ) (Revisions to care plan? D/C care plan? Continue care plan?) Energy Field Disturbance Related to: Slowing or blocking of energy flow secondary to labor. Defining Characteristics: Disruption of the client's energy field as perceived by nurse experi- enced in therapeutic touch (specify: e. g., tempera- ture, color, disruption, or movements of the visual field). Goal: Client will regain harmony and energy field balance by (date/time to evaluate). Outcome Criteria Client reports feelings of relief after therapeutic touch. Labor progress resumes. INTERVENTIONS RATIONALES Assess possible causes of failure to progress. If phys- iological causes are not apparent, note if client exhibits psychological dis- tress. Explain therapeutic touch to client and assess client's desire for the intervention. Reassure client that she may stop the procedure if she feels uncomfortable. Notify a nurse qualified to perform therapeutic touch Assessment provides infor- mation about the possible causes of failure to progress. Psychological fac- tors may hinder labor progress. Client may not know about therapeutic touch as an intervention. Permission needs to be obtained and client safety assured before any inter- vention. Reassurance may encour- age client to try this inter- vention. Practitioners of therapeutic touch have had specialized | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 119 INTERVENTIONS RATIONALES of client's request for the intervention. Provide privacy and avoid interruption of the process (e. g., time labor assess- ments to promote uninter- rupted time for therapeutic touch). Encourage and facilitate rest after therapeutic touch is completed. Evaluate client's verbal and nonverbal response to intervention. Monitor labor progress. instruction and supervised practice. Therapeutic touch is a very personal experience. The practitioner needs to focus on the client's energy field in order to facilitate the flow of healing energy. Rest promotes harmony and balance of energy flow. Evaluation provides infor- mation about effectiveness of intervention. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client report feelings of relief? Specify using quotes. Has labor progressed? Specify changes in dilatation or descent. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
120 MATERNAL-INFANT NURSING CARE PLANS Failure to Progress Passageway Passenger Powers contracted pelvis macrosomia hypo tonic contractions cervical scarring abnormal presentation or uncoordinated contractions analgesia/ anesthesia pathological retractiok ring maternal positioning position 1 psychological factors fear, tension ack of progress--i cervical dilatation and/or fetal descent after active labor has begun / Labor \ Maternal Fetal infection exhaustion uterine rupture post partum hemorrhage distress birth trauma | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 121 Fetal well-being during labor is assessed by evalua- tion of the FHR pattern. The healthy fetus is able to compensate for the normal interruption of oxy- gen delivery during the peak of contractions. A reassuring FHR pattern includes a stable individ- ual baseline rate (usually between 1 l&l6O), pres- ence of variability (notably STV; assessment ter- minology varies), presence of accelerations and absence of variable or late decelerations. When the oxygen supply is inadequate to meet fetal needs, changes in the FHR pattern indicate fetal distress. Common causes are placental insuf- ficiency, cord compression, and anemia. Signs of fetal distress include decreased fetal movement, nonreassuring or ominous FHR patterns, and meconium in the amniotic fluid {unless fetus is a breech presentation). Risk Factors c e 0 e 0 * * e PIH diabetes mellitus uterine hypertonus hemorrhage infection maternal h~potens~on maternal or fetal anemia oligohydramnios cord entanglement/prolapse preterm or IUGR fetus M~di~al Care continue oxytocin, change maternal position, give humidified oxygen at 8-12 Llmin. Fetal scalp sampling * ~n~oin~sion Delivery by forceps, vacuum extraction, or cesarean section if indicated Nursing Care Plans Anxiety (99) Related to: Threat to fetal well-being, perceived possible fetal loss or injury. Defining Characteristics: Client expresses anxiety (specify using quotes: e. g., “I'm scared. Is my baby going to be all right?”). Client exhibits physiologi- cal signs of anxiety (specify: e. g., tension, pallor, tachycardia, etc. ). Additional Diagnoses and Plans Gm Ekchmge, Impaired: Fetal Related to: Inadequate oxygen supply secondary to (specify: placental insufficiency, cord compres- sion, or anemia). Defining Characteristics: (Specify details of non- reassuring or ominous FHR pattern, BPP find- ings, laboratory values: e. g., materna I Hgb, fetal scalp p H, 0, and CO, if available). Goal: Fetus will experience improved gas exchange by (datehime to evaluate). Outcome Criteria FHR returns to individual baseline rate with a reassuring pattern: present STV, no late or severe variable decelerations. APGAR score is > 7 at 1 and 5 minutes. Continuous EFM with scalp electrode; IVE dis- | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
122 MTERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Monitor FHR, contrac- tions, and resting tone continuously by EFM and palpation. Apply scalp electrode if possible. Assess FHR systematically q 15 min during 1st stage and q 5 min during 2nd stage of labor. Assess color, amount, and odor of amniotic fluid when membranes rupture and hourly thereafter. Assess for vaginal bleeding, abdominal tenderness, or '?' abdominal girth. Assess maternal B/P, P, and R on same schedule as FHR assess temp q 2h after ROM. Discontinue oxytocin if infusing and the fetus shows signs of distress. Ensure adequate maternal hydration. Increase rate of IV or start IV as ordered (specify: fluid, site, rate). Administer humidified oxygen at 8-12 Llmin via facemask. Explain rationale to client and significant others. Position client on left side. If severe variable decelera- tions occur, try alternative Monitoring provides con- tinuous information about fetal oxygenation. Internal scalp electrode provides the most accurate FHR information. Frequent assessment for high-risk clients provides information about fetal well-being and response to interventions. Assessment provides infor- mation about passage of meconium, bleeding, pos- sible oligohydramnios, or development of infection. Assessment provides infor- mation about possible pla- cental abruption. Assessment provides infor- mation about maternal homeostasis and possible development of chorioam- nionitis. Oxytocin may cause uter- ine hypertonus, which interferes with placental perhion and fetal oxy- genation. Maternal dehydration and hypovolemia 4 placental perfusion and fetal oxygen Intervention provides '?' oxygen saturation of maternal blood perhsing placenta. supply. Positioning the client on her left side facilitates pla- cental perfusion. INTERVENTIONS RATIONALES positions: left, right sides, knee-chest, etc. Explain purpose to client and sig- nificant others. Perform sterile vaginal exam if indicated to rule out prolapsed cord and evaluate labor progress. If prolapsed cord is felt or suspected (severe variable decelerations or bradycar- dia), keep hand in vagina and apply pressure to hold presenting part off the cord. Position client in knee-chest or trendelen- burg and call for help. Administer tocolytic med- ication as ordered (specify: e. g., terbutaline 0. 25 mg SC). Evaluate and document fetal response to interven- tions. Notify caregiver of FHR pattern, interventions, and fetal response. Offer calm explanations and reassurance to client and significant others while providing care. Implement amnioinfusion as ordered (specify: fluid, rate, warmer, etc. ). Alternative positions may relieve cord compression indicated by variable decel- erations. Explanations pro- mote client compliance. Vaginal exam provides information about possible causes of distress. Compression of a pro- lapsed cord interferes with oxygen delivery to the fetus. Rapid fetal descent may cause a prolonged deceleration. Contraction pressure caus- es the prolapsed cord to be occluded causing fetal dis- tress or death. Interventions help relieve pressure of the cord until fetus can be delivered by cesarean. Tocolytics 4 uterine activ- ity and improve fetal oxy- genation if uterine hyper- tonus or a prolapsed cord is causing distress. Evaluation provides infor- mation about effectiveness of interventions. Notification provides care- giver with information about fetal status. Interventions for fetal dis- tress may be frightening to client and her family. Amnioinfusion may 4 cord compression and dilute thick meconium to | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 123 INTERVENTIONS RATIONALES INTEKVENTIONS RATIONALES Assist caregiver with fetal scalp sampling if needed. Prepare client for delivery if indicated (specify: for- ceps, vacuum extractor, or cesarean). Notifjr neonatal caregivers (specify: pediatrician, neonatologist, NICU) of fetal distress and expected birth route and time. Provide additional equip- ment as needed for birth (specify: e. g., forceps, vac- uum extractor, delee mucous trap, etc. ). Ensure that neonatal resus- citation equipment is ready and in working order and preheat warmer before every birth. Implement or assist with neonatal resuscitation at birth: dry infant quickly, clear airway (intratracheal suctioning for thick meco- nium), stimulate crying, assess respiration, HR, and color. Provide oxygen, PPV, chest compressions, and drugs as indicated/ordered. prevent fetal or neonatal meconium aspiration. Assistance helps obtain a sample of fetal blood used to determine acid-base sta- tus. Preparation facilitates emergency delivery of the distressed fetus who has not responded to intrauter- ine resuscitation efforts. Notification ensures that caregivers are prepared to resuscitate the newborn at birth. Preparation avoids delay when delivery is needed for fetal distress. Thick meconium should be suc- tioned from the pharynx after birth of the head. Interventions avoid delays after infant is born. Warmer prevents cold stress that further compro- mises oxygenation in the newborn. Nurses present at delivery should be prepared to resuscitate the newborn until medical assistance is available. A person skilled at intubation should be present at all births. Interventions promote neonatal oxygenation. Assess APGAR score at 1 and 5 minutes after birth (continue q 5 min until score is greater than 6). Allow parents to see and touch infant before trans- fer to the nursery or NICU. Discuss events with client and significant other after infant is transferred. APGAR assessment pro- vides quantitative measure- ment of fetal oxygen and neurological status. Intervention promotes attachment and bonding. Discussion promotes client understanding of unfamil- iar events. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Describe FHR pattern after interventions. What was Apgar score at 1 and 5 minutes?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
124 MATERNAL-INFANT NURSING CARE PLANS Fetal Distress Cord Compression Placental Insufficiency Anemia prolapse +B/P maternal placental infarct uterine hypertonus oligo hydraminos hemorrhage fetal isoimmunization / Fetal Hypoxemia 1 Compensatoryv Mechanisms 1 possible tissue hypoxia homeostasis hypercapnia (+ 02) 1 Organ r anaerobic metabolism (+ lacti acid) 5 4 metabolic acidosis (+H+, + PHI cell destruction I respiratory acidosis (+H+, + PHI permanent disability or death | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 125 Abruatio Placentae Placental abruption is the separation of a normally implanted placenta before birth of the baby. The separation may be partial or complete. A marginal abruption describes detachment of the edges of the placenta. Partial separation may also occur in the center of the placenta. With a total placental abruption the entire placenta detaches. Hemorrhage from the exposed surfaces may be obvious or occult. The amount can vary from mild with a marginal abruption to torrential with a total separation. Classic symptoms of abruption are abdominal tenderness and board-like abdomi- nal rigidity with or without vaginal bleeding. Fetal prognosis is poor if > 50% of the placenta detach- es. Maternal complications include development of DIC, hypovolemic shock, kidney or heart fail- ure, and increased risk for post partum hemor- rhage. The cause is unknown but abruptio placen- tae may be associated with hyptertensive disorders, maternal cocaine use, abdominal trauma, and uterine overdistention. Ultrasound examination of the placenta IV fluid and electrolyte replacement; blood transfusion as needed Laboratory studies to rule out DIC: platelets, fibrinogen, fibrin degradation products, PT, and PTT Cesarean delivery if the fetus exhibits distress Vaginal delivery may be preferred for a fetal demise or if the fetus is tolerating a partial abruption Close observation may be employed if the abruption is small, the fetus is immature, and appears stable Fluid blume Deficit, Risk for (36) Related to: Excessive losses secondary to prema- ture placental separation. Impaired Gas Exchange: Fetal (121) Related to: Insufficient oxygen supply secondary to premature separation of the placenta. Defining Characteristics: Signs of fetal distress (specify: loss of variability, late decelerations, tachycardia, or bradycardia, etc. ). Fear (129) Related to: Perceived or actual grave threat to body integrity secondary to excessive bleeding, and threat to fetal survival. Defining Characteristics: Client verbalizes fare (specify using quotes). Client exhibits physiologic sympathetic responses (specify: e. g., dry mouth, pallor, tachycardia, nausea, etc. ). Additlonal Diagnoses and Plans Tkue Perfkion, Altered (phcental, renal: cerebral: peripheral) Related to: Excessive blood loss secondary to pre- mature placental separation. Defining Characteristics: (Specify: estimated blood loss, FHR pattern, B/P compared to base- line, pulse, severe abdominal pain and rigidity, pallor, changes in LOC, J( urine output, etc. ). Goal: Client will maintain adequate tissue perfu- sion by (dateltime to evaluate). Outcome Criteria Client will maintain B/P and pulse (specify for client: e. g., > 100/60, pulse between 60-90), skin | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
126 ~TE~~-INF~T NURSING CARE PLANS warm, pink, and dry. Urine output > 30 cdhr. Client will remain alert and oriented. FHR pat- tern remains reassuring. Assess client's Sa02, BR P, and R (specify frequency). Monitor for restlessness, anxiety, “air hunger,” and changes in level of con- sciousness. Monitor all intake and output (insert foley catheter as ordered). Evaluate blood loss by weighing peri pads or chux (1 gm = I cc). (Specift fre- quency of documentation. ) Notify caregiver of f losses. Continuously monitor FHR pattern and compare to baseline data from pre- natal record. Inform care- giver of nonreassuring changes. Assess for uterine irritabili- ty, abdominal pain, rigidi- ty, and increasing abdomi- nal girth (measure abdomen at umbilicus). {Specify frequency. ) Assess client's skin color, temperature, moisture, tur- gor, and capillary refill (specify frequency). Assessment provides infor- mation about client's tissue perfusion. Hypovolemia Causes 4 BJP with f P and f R as compensatory mechanisms for C perfu- sion and hypoxemia. Intervention provides information of developing indications of inadequate cerebral tissue perfusion. Monitoring provides infor- mation about renal perfu- sion and function and the extent of blood loss. Partial abruption may progress rapidly to complete abrup- tion. The fetus may initialfy respond to 9 placental perfusion by raising the FHR above the normd baseline. Nonreassuring FHR is an indication for delivery. Assessment provides infor- mation about severity of placental abruption. Bleeding may be occult causing abdominal rigidity and pain. Assessment provides infor- mation about peripheral tissue perfusion. Hypovolemia results in INTERVENTIONS RATIONALES Initiate IV access with 18 gauge (or larger) catheter and provide fluids, blood products, or blood as ordered (specify fluids and rate). Monitor laboratory values as obtained (e. g., Hgb, Hct, cloning studies). Observe client for signs of spontaneous bleeding (e. g., bruising, epistaxis, seeping from puncture sites, hema- turia, etc. ). Keep client and significant other informed of condi- tion and p Ian of care. Notify caregivers and pre- pare for immediate deliv- ery and neonatal resuscita- tion if maternal or fetal shunting of blood away from the peripheral circu- lation to the brain and vital organs. Intervention provides venous access to replace fluids. Size 18 gauge or larger is preferred to trans- fuse blood. Laboratory studies provide information about extent of blood foss and signs of impending DIC. Observation provides information about the depletion of dotting fac- tors and development of DIC. Infor~ation promotes unde~tanding and cooper- ation. Continued blood loss or development of DIC may lead to maternal or fetal injury or death. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What is client's BIP and P? Is skin warm, pink, and dry? Is urine output > 30 cclhr? Is client alert and oriented? Describe FHR pattern. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 127 Abruptio Placentae Possible Causes hypertension cocaine abuse trauma sudden changes in intrauterine pressure Partial Separation Margnal central (symptoms depend on degree of separation) (symptoms depend on degree of separation) 4 mild to moderate 1 mild to moderate vaginal bleeding concealed bleeding L uterine irritability J (if progressive separation) 4 4 uterine tetany fetal distress (J, variability) (late decelerations) > 500/0 separation severe fetal distress 4 emergency delivery Total Separation 1 massive vaginal or concealed hemorrhage abdominal/ back pain + abdominal girth fetal death (loo??) T maternal shock J/B/P, +P I . L platelets J/ fibrinogen + fibrin degradation products I DIC renal failure heart failure | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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INTRAPARTUM Prolansed Cord Prolapse of the umbilical cord may occur when the membranes rupture and the presenting part is not well-engaged and seated against the cervix. The cord is then washed down in front of the pre- senting part. Pressure from contractions compress- es the cord against the presenting part resulting in fetal distress or death from hypoxia. An occult prolapse occurs when the cord is wedged between the presenting part and the cervix but cannot be seen or felt by the examiner. Severe variable decel- erations and fetal bradycardia after ROM are signs of a prolapsed cord; either occult or palpable/visi- ble. Risk Factors small fetus (preterm or IUGR) contracted pelvis transverse lie or complete or footling breech presentation multiple gestation hydraminos labor with an unengaged fetus, grand multi- parity Medical Care 129 If the cord is pulsating, the fetus is alive and rapid cesarean delivery is indicated Nursing Care Plans Gas Exchange, Impaired Fetal (121) Related to: Insufficient oxygen delivery secondary to cord occlusion. Defining Characteristics: Signs of fetal distress (specify: severe variable decelerations, loss of vari- ability, etc. ). Additional Diagnoses and Plans Fear Related to: Perceived grave danger to fetus and self from obstetric emergency. Defining Characteristics: Client states (Specify: e. g., “I'm scared; This can't be happening!” etc. ). Client is crying, confused, appears pale, ?' P and R, dry mouth, etc. (specify). Goal: Client will cope with fear during emer- gency. Outcome Criteria Client and significant other can identify the threat. Client is able to cooperate with instruc- tions from caregivers. Prevention: bedrest with bulging or ruptured membranes and an unengaged fetus Pressure is applied to the presenting part to hold it off the cord until birth Client may be placed in knee-chest or trende- lenburg position to relieve cord compression until birth. These measures are often imple- mented by nurses who are the first to identifj the emergency INTERVENTIONS Inform client and signifi- cant other of a problem as soon as it's identified. Speak slowly and calmly. Describe the problem in simple terms and what RATIONALES Calm information decreas- es client and significant other's fear. It is more frightening to “sense” that something is wrong than to know what it is. Simple explanations are less frightening than com- | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
130 MTERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES interventions might be expected (specify: e. g., for prolapsed cord the nurse will hold the baby up until a cesarean can be done). Explain all equipment and procedures as they're being done (specify: e. g., foley catheter, IV etc. ). Inform client and signifi- cant other of things they can do to help (specify: e. g., position changes; keep oxygen mask on; sig- nificant other can support client breathing and relax- ation, etc. ). Observe client and signifi- cant other for signs of dis- tress: pallor, trembling, crying, etc. Provide emotional support; validate fears. Encourage significant other to remain with client during birth if possible. Inform client and signifi- cant other of infant's con- dition at birth. Allow client and signifi- cant other to hold infant as soon as it is born. Defer nonessential newborn care (if condition allows). Praise client and signifi- cant other for their coop- eration and coping during a stressful birth. plicated physiology or medical terminology the client may not understand. Explanation promotes understanding of unfamil- iar interventions and decreases fear of the unknown. Information promotes a sense of control over frightening events by allowing client and signifi- cant other to be involved in the solutions. The “fight or flight” sym- pathetic response may indicate f fear. Significant other may need attention. Emotional support and validation helps client and significant other to cope with fears. Information increases a sense of control and ability to cope. Intervention provides reas- surance that the baby is all right and promotes par- ent-child attachment and bonding. Praise enhances self- esteem. Intervention shows that the client's abilities are valued. Visit client afier birth (specify when: e. g., 1st or 2nd PP day) to discuss events surrounding birth. Clarify any misconceptions about the emergency. before discharge. Discussion provides an opportunity for client and significant other to relive the experience and fill in any gaps in understanding Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did client and significant other verbalize correct understanding of the emergency? Was client able to cooperate with instructions? Specify. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 131 Prolapsed Cord Unengaged Presenting Part SROM/AROM I cord precedes presenting part occlusion fetal arteries occlusioi fetal vein '1 acute hypoxia f--fetal hypotension + C02 buildup respiratory acidosis sympathetic response + (+epinephrine 86-norepinephrine) tissue hypoxia *1' FHR 1 I baroreceptor stimulation 1 vagal response 1 + J* oxygen anaerobic metabolism ' I 1 + lactic acid * \L FHR J* FHR 1 metabolic acidosis | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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INTRAPARTUM 133 Medical Care Careful determination of dates: LNMR fundal A pregnancy that continues to 42 weeks or more after the LNMP with fertilization two weeks later, is considered to be postterm. The postterm fetus is at higher than normal risk for hypoxia, birth height, serial ultrasound measurements Daily fetal movement counts by client after 40 weeks-. ~ injury, meconium aspiration, and hyperbilirubine- mia in the neonatal period. The cause of pro- longed pregnancy is unknown though some con-Meekly cervical exam, NST and ultrasound for amount of amniotic fluid; may be 2 times per ........ week after 42 weeks..-_-_ _--__--..-.--_ genital anomalies are associated with postterm- birth including anencephaly and congenital adren- al hypoplasia. Sometimes the date of the LNMP is hard to deter- mine, or the woman may have had a long men- strual cycle in which case the fetus really isn't post- term even at 42+ weeks. The truly postterm neonate has a characteristic appearance. The infant appears alert, is long and thin with abundant scalp hair and long finger- nails. The skin may be meconium stained, loose, dry and peeling, with little subcutaneous fat. No vernix or lanugo are present. fetal macrosomia; birth trauma, shoulder dysto- cia, cesarean birth oligohydramnios: dry, cracked skin; cord com- pression & acute hypoxia placental aging with 6 exchange of oxygen and nutrients: chronic hypoxia; fetal loss of subcuta- neous tissue: appears long and thin passage of meconium due to hypoxia; meconi- um staining risk for aspiration polycythemia Other fetal testing possible: BPP or OCT (CST) Induction at 42 weeks if dates are accurate and cervix is favorable Uncertain dates: close surveillance with induc- tion if J( fetal movement perceived by the mother or 6 amniotic fluid Fetal monitoring during labor with scalp elec- trode and possibly IUPC; possible amnioinfu- sion Cesarean birth for unsuccessful induction Suctioning of oropharynx after birth of the head and before birth of the chest, tracheal suc- tioning before infant is stimulated for the first breath Nursing Care Plans Gas Exchange, Impaired Fetal (12I) Related to: Aging placenta, oligohydramnios and cord compression. Defining Characteristics: Signs of fetal distress (specify: e. g., decreased variability, late decelera- tions in labor). | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
~ 134 MATERNAL-INFANT NURSING CARE PLANS Injury, Risk fir: Maternal and Fetal (93) Related to: Fetal macrosomia, risk for shoulder dystocia. Anxiety (99) Related to: Prolonged pregnancy and threat to fetal well-being. Defining Characteristics: Client expresses concern about prolonged pregnancy (specify using quotes). Client states she is worried about the baby (speci- fy). Additional Diagnoses and Plans Aspiration, Risk for Fetal/Neonatal Related to: Passage of thick meconium in the amniotic fluid prior to birth. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will not aspirate meconium at birth. Outcome Criteria Infant does not experience aspiration of meconi- urn. Airway is clear, respirations at birth are 40- 60. INTERVENTIONS RATIONALES Assess color and character of amniotic fluid when membranes rupture and each hour thereafter and during each vaginal exam. Notify primary caregiver if fluid is meconium stained and fetus is not breech presentation. Assessment provides infor- mation about passage of meconium and whether it is thin or thick. Thick meconium is more likely to cause meconium aspira- tion syndrome. Notification allows care- giver to consider amnioin- fusion and plan for suc- tioning at birth. A breech may pass meconium due to pressure, not hypoxia. INTERVENTIONS RATIONALES Monitor fetus continuous- ly during labor. Note non- reassuring patterns and notify caregiver. Apply scalp electrode to deter- mine STV if indicated. Ensure that a caregiver skilled at tracheal suction- ing and incubation is pre- sent at every delivery. Ensure that all infant emergency equipment is ready at birth. Arrange laryngoscope, suction, and catheter for immediate use. Preheat overhead warmer. Instruct client that she will need to stop pushing after the head has been born so that meconium may be suctioned before the baby breathes. When the head is deliv- ered, assist client to avoid pushing by panting or blowing. Afkr the caregiver has suc- tioned the oropharynx and nasopharynx, gently carry infant to warmer, fold warm blanket over baby and assist with tracheal suctioning. Do not stimu- late infant until after tra- cheal suctioning. Auscultate the infant's breath sounds and note respiratory rate and effort (specify how frequently). A postterm fetus may experience chronic or acute hypoxia due to aging of the placenta or oligohy- dramnios. Presence of a skilled care- giver allows for smooth and prompt suctioning of meconium below the vocal cords before the first breath is taken. Preparation avoids delay in tracheal suctioning afcer infant is born. Maintaining warmth 4 infant's metabolic needs and oxygen requirements. Instruction ensures mater- nal cooperation while the pharynx is being suc- tioned. Panting or blowing keeps the glottis open and 4 maternal bearing-down efforts. Interventions allow the mouth and nose to be cleared of meconiurn, and the trachea to be visualized and suctioned before the infant is stimulated and takes its first breath. Assessments provide infor- mation about success of interventions. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
Document and norif L nursery personnel of meconium fluid and inter- ventions at delivery. ~oti~~ti~n, in addition to documentauan, ensures continuity of care. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did infant aspirate meconium? Was any meconi- um suctioned from the phap or trachea? 1s air- way clear? What is respiratory rate?) (Revisions to care plan? D1C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
136 MATERNAL-INFANT NURSING CARE PLANS Postterm Birth macrosomia (> 4000 g) J, nutrients I CPD shoulder dystocia 1 birth trauma 'tdt WGGJSS I 4 placental aging . L oxygen A 3 hypoglycemia polycythemia 1 J. subcutaneous tissues “old man” appearance v hyperbiliru binemia. L amniotic fluid cord compression acute 1 chronic hypoxia hypoxia I \1. ven dry skin cracks meconium staining meconium aspiration syndrome (MAS) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
Precipitous labor Precipitous labor is defined as a labor that lasts three hours or less from start to finish. Precipitous birth is any birth that happens much bter than is normally anticipated. This may result in an unat- tended birth. The fetus may suffer head trauma from rapid descent through the birth canal. When the contractions are very intense or tumultuous, the mother is at risk for lacerations: cervical, vagi- nal, perineal, periurethral, or even uterine rupture. This we of rapid intense labor may also be asso- ciated with amniotic fluid embolus or postpartum hemorrhage. Clients who are at risk for precipitous labor and birth are those who have had a previous precipi- tous ~abor/bir~; clients with a large pelvis or a smaif fetus; and cfients with uterine hypertonus. Close observation of clients with risk factors; client may be asked to stay close to the hospital as she reaches term gestation Client may be induced if she lives far from the hospital Tocolytics may be used to decrease the intensity of contractions Hu~~n~ Care Plans Pain (II2) Related to: Tumultuous labor contractions and maternal tension. Defining Characteristics: CIient verbalizes acute pain (specify using quotes or a pain scale). Client is (specie: crying, grimacing, etc. ). Fear (123) Related to: Perceived threat to self and fetus sec- ondary to rapid labor progress, possibility of unat- tended birth. Defining Characteristics: Client verbalizes fear (specify using quotes), Client exhibits physi~logi- cal signs of sympathetic response (specify: e. g., tachycardia, tachypnea, dry mouth, pallor, tremors, etc. ). Additional Diagnoses and Plans Tissue Integrity, Risk for Impaired Related to: ~ec~an~~ trauma from uterine hypertonus and rapid fetal descent. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client will not experience tissue injury dur- ing birth. Outcome Criteria Perineum is intact after delivery. INTERVENTIONS RATIONALES Palpate contractio~ for frequency, duration, inten- sity, and resting tone (spec- ify frequency). Assess FHR per agency protocol (speci- +I- Notify caregiver if uterine resting tone lasts less than 60 seconds between con- tractions. Stay with the client experi- encing tumultuous con-Assessments provide infor- mation about hypertonic uterine activity and fetal well-being. Notification provides information about fetal risk. The caregiver may elect to use tocolytics to 9 resting tone to improve placental perfusion. Staying with the client avoids an unattended | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
138 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES tractions. Provide reassur- ance. Obtain precip equipment. Notify caregiver of rapid progress. Wash hands, open precip pack; don sterile gloves if birth appears imminent. Encourage client to blow or pant if the urge to push occurs before complete cervical dilatation. Support the client's per- ineum as the head crowns. Ask client to blow as the head delivers. Suction the infant's nose then mouth. Check for a nuchal cord and slip over the head or double-clamp and cut the cord. Guide infant's body down to slide the anterior shoul- der under the symphysis pubis, then up to deliver the posterior shoulder. Observe client for signs of placental separation. Ask her to push to expel the placenta. After the placenta and membranes completely deliver, massage the uterus, put the infant to breast, and/or administer oxytocin per standing orders (speci- fy: drug, dose, and route). birth. Client may be frightened by the intensity of the contractions. vaginal bleeding. sue injury. Preparation allows a sterile controlled birth by caregiv- er. Sterile technique pre-infant per protocol until vent complications. vents the introduction of microorganisms during Assess perineum for lacera- tions, hematomas, or 9 Assessment provides infor- mation about possible tis- Provide routine post-deliv- ery care to mother and caregiver arrives. Post delivery care promotes attachment and helps pre- birth. Evaluation Intervention may help avoid cervical or vaginal lacerations. Gentle counter pressure and a slow delivery of the head help prevent rapid expulsion and tearing of the perineum. Guidance during birth helps prevent perineal or vaginal tears during deliv- ery of the infant's shoul- ders. As the placenta separates, there may be an 9 in bleeding, the cord may lengthen, the hndus changes shape. Maternal pushing facilitates delivery of the placenta. Interventions help prevent excessive postpartum bleeding by stimulating contraction of the uterus via mechanical and endogenous or exogenous oxytocin. (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Were any lacerations noted after delivery?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTW'ARTUM 139 Precipitous labor and Birth Labor e 3 hours Rapid Birth Fetal Effects Maternal Effects 1 hypkia head trauma lacer&ions amniotic fluid embolus hemorrhage | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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INTRAPARTUM 141 HELLP is a complication of PIH that may or may not advance to disseminated intravascular coagula- tion (DIC). HELLP stands for Hemolysis, Elevated Liver enzymes (AST & ALT), and Low Platelets. The underlying pathology is vasospasm that results in damage to the endothelial layer of small blood vessels. Platelets adhere to the vessel lesions (resulting in low serum platelet levels), fib- rin is deposited, and red blood cells are damaged (hemolysis) as they are forced through the vessel. Microemboli clog the vasculature of organs result- ing in ischemia and tissue damage (elevated liver enzymes). The treatment is delivery and resolution of PIH. Disseminated Intravascular Coagulation (DIC) is also known as consumptive coagulopathy. The normal coagulation process is overstimulated and the coagulation factors are used up. This places the client at risk for hemorrhage. The underlying pathology may be endothelial damage as in HELLP, or tissue damage resulting in release of thromboplastin. DIC may be associated with abruptio placentae, chorioamnionitis, sepsis, fetal demise, or retained products of conception. Subtle signs of DIC include bleeding from injection sites, spontaneous bleeding from the nose or gums, bruises, and petechiae. The treatment is delivery and correction of the underlying cause. lab Value Changes HELLP DIC Fibrinogen J1 J( Fibrin degradation 9 9 Platelets 4 4 products (FDP, FSP) PT and PTT wnl prolonged HELLP: Stabilization of PIH (Mg SO,) induc- tion, and delivery either vaginal or cesarean DIC: Stabilization and delivery, preferably vagi- nal without an episiotomy N fluids with a 16 or 18 gauge cannula, foley catheter, intake and output Transfusions with packed RBC's Fresh frozen plasma (FFP) to replace fibrinogen and clotting factors Cryoprecipitate to replace fibrinogen Nursing Care Plans Fluid Volume D@cit, Risk for (96) Related to: Excessive losses secondary to inade- quate protective mechanisms. Gas Exchange, Impaired-Fetal (121) Related to: Maternal microangiopathic hemolytic anemia secondary to coagulopathy. Defining Characteristics: Signs of fetal distress (specify: e. g., loss of FHR variability, late decelera- tions, tachycardia, or bradycardia). cerebral, Tissue “T epatic) (I25) Related to: Vascular occlusion by microemboli secondary to consumptive coagulopathy. Defining Characteristics: (Specify: e. g., Fetal IUGR, oliguria, BUN and creatinine, changes in LOC, liver enzymes, etc. ) Fear (129) ion, Altered (phcental, renal, Related to: Threat to physiologic integrity of | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
142 MATERNALINFANT NURSING CARE PLANS client and fetus secondary to serious complication INTERVENTIONS RATIONALES of pregnancy. Defining Characteristics: Client and family express fear (specify using quotes). Client exhibits as ordered per agency pro- tom1 (specify: product, amount, and time). clotting factor losses. -~ signs of fear (specify: e. g., crying, withdrawn, tremors, pallor, etc. ). Additional Diagnoses and Plans Protettion, Altered Related to: Abnormal blood profile: thrombocy- topenia, anemia, decreased clotting factors. Defining Characteristics: Altered clotting (speci- fy: e. g., platelets < 50,OOO/p L, fibrinogen < 300 mg/d L, ?' fibrin degradation products, prolonged PT and PTT, 4 Hct, etc. ). Bleeding from nose, gums, and injection sites. Petechiae, bruising, etc. (specify). Goal: Client will regain intrinsic protection mech- anisms by (date/time to evaluate). Outcome Criteria Client does not exhibit bleeding from injection sites, gums, etc., (specifjr for client). Clotting fac- tors increased to (specify for client: e. g., platelets 2 1 50,000/p L, fibrinogen 2 300 mg/d L). INTERVENTIONS RATIONALES Assess client for signs of abnormal bleeding from injection sites, oozing from IV, mucous membranes, ting deficiencies. bruising, or petechiae. Start and maintain IV access with a 16 or 18 gauge cannula (specify flu- ids and rate as ordered). Assessment provides infor- mation about subtle signs of bleeding related to clot- IV access allows rapid medication administration and replacement of fluids, blood, and blood products. Large bore IV cannulas are needed for RBC replace- ment. Administer PRBC's, FFP, Intervention provides and/or cryoprecipitate IV replacement of blood and Monitor for transfusion reactions: changes in v/s, chills, fever, urticaria, rash-Monitoring allows prompt recognition and treatment of transfusion reactions. es, dyspnea, and diaphore- sis throughout transfusion per agency protocol. Gently insert and anchor a foley catheter. Monitor hourly intake and output. Notify physician if output < 30 cclhr. Monitor laboratory values as obtained for improve- ment or worsening of con- dition. Pad sides of bed with bath blankets. Avoid any trau- ma or breaks in the client's skin (e. g., injections). If injection is necessary, apply pressure for 5 full minutes afier needle is removed. Position client on her left side and monitor fetus continuously using soft EFM belts. Take manual B/P rather than electronic. Wrap cuff gently around extremity without wrinkles. Explain clotting deficiency and treatment to client and significant other. Offer reassurance and support. Gentle insertion prevents trauma and bleeding. Renal vascular occlusion may occur leading to ischemia and necrosis. Laboratory values may provide information about clotting profile, renal and hepatic function. Monitors the effect of treatment on condition. Padding prevents bruis- ing/bleeding from mechanical trauma. Avoiding breaks in the skin maintains vascular integri- ty to prevent hemorrhage. Position promotes placen- tal perfusion. Tight belts may cause bruising. Electronic B/P machines may inflate the cuff too tightly and cause bleed- ing/bruising. Client and significant other may be confused and frightened by unfamiliar interventions. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 143 Evaluation (Date/time of evaluation of goal. ) (Has goal been met? not met? partially met?) (Does client exhibit any bleeding? What are clot- ting factor lab values?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
144 MATERNAL-INFANT NURSING CARE PLANS Disseminated lntrauascular Coagulation 6 Release of Tissue Thromboplastin 1 Vascular Endothelial Damage sepsis I 1 Intrinsic Pathway. Extrinsic Pathway INTRAVASCULAR C~A~U~TIO~ i J, clotting factors 9 fibrinogen-+ fibrin _I+ 3. fibrinogen levels fhrombocytopenia i microemboli 1 'E fibrinolysis i vascular occlusion (+ fibrin degradation ischemia products, FDP- anticoagulant) Hemorrhage 1 renal necrosis ARDS | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
Prostaglandin E, suppositories may be used before 28 weeks to induce labor Analgesia and sedation is often ordered EFM may be applied with the toco only or an IUPC inserted Fetal death after 20 weeks gestation is often referred to as an Intrauterine Fetal Demise (IUFD) or stillbirth. Causes of fetal demise may be related to complications of pregnancy such as PIH, diabetes, hemorrhage, a cord accident, or fetal anomalies. No apparent cause is found in approximately 25% of cases. The mother may notice a lack of fetal movement and decreased breast size. Fundal height may not correlate with expected gestational age. Frequently the first sign is an absence of FHT on ausculta- tion. Fetal death is confirmed by real-time ultra- sound. Ninety percent of women will sponta- neously labor and deliver within three weeks of fetal death. When the pregnancy continues beyond a month, the mother is at risk for devel- oping DIC due to the release of tissue thrombo- plastin. The attachment process begins early in pregnancy. Fetal demise represents an emotionally devastating tragedy for the mother and family. Normal grief responses that may be noted during labor include denial, anger, bargaining, and depression. The birth of a subsequent baby may be accompanied by renewed grief for the lost child. May wait 2 to 3 weeks if client desires, to see if labor begins spontaneously Monitoring of blood clotting factors to avoid DIC Induction with oxytocin if near term and cervix is favorable Use of cervical ripening agents followed by oxy- tocin if cervix is unfavorable Autopsy to determine cause of death Nursing Care Plans Any of the intrapartum care plans would be appropriate without interventions designed to ensure fetal well-being. Injury, Risk fir Related to: Effects of suppository medications used to terminate pregnancy with IUFD before 28 weeks. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client will not experience any injury during labor or birth. Outcome Criteria Client's vital signs remain stable (specify for client, give ranges for temperature, B/P, P, and R. EBL < 500 cc after birth. INTERVENTIONS RATIONALES Assess TPR, B/P, and con- traction status prior to insertion of suppository. May place toco only of fetal monitor or use palpa- tion to assess contractions. Explain procedure and expected outcome to client Assessment provides base- line information about maternal homeostasis and uterine activity. Explanations help the client and significant other | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
146 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RKTIONALES (specify: e. g., vaginal sup- positories initiate contrac- tions; birth is usually accomplished within 24 hours). Position client supine for 10-1 5 minutes after sup- pository is inserted. Administer aceta- minophen, antidiarrheal, and antiemetic drugs as ordered (specify drug, dose, route, and times). Monitor vital signs during induction per protocol (specie: e. g., B/P, P, R q 30 min, temp q 2h etc. ). Monitor client for cramp- ing or contractions. Notify physician if pain or vaginal bleeding appears excessive. Count or weigh pads for more than expected amounts of bleeding. Provide pain medication as needed (specify: drug, dose, route, and time). Notify caregiver if cramp- ing subsides without s&- cient cervical sofiening and dilatation. Perform vaginal exams only as needed. Observe client for signs of second stage expulsive efforts. Initiate oxytocin induction as ordered and per proto- col. to anticipate what will happen next. Facilitates coping with unfamiliar experience. Positioning facilitates absorption of drug and prevents expulsion. Prophylactic medications help C adverse effects of drug. PGE, causes fever, nausea, vomiting, and diarrhea in most clients. Vital signs provide infor- mation about complica- tions of induction and adverse effects of medica- tions. Fever is a normal response to PGE,. Drug may cause intense contractions that could result in uterine rupture. Pad count or weighing helps estimate EBL (1 g = 1 cc). Describe action of specific drug. Drug dose may need to be repeated after 6 hours up to 3 doses. Client's labor may progress more rapidly than usual. Once cervix is softened, oxytocin may be effective in inducing labor. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What are client's vital signs? What is EBL after delivery?) (Revisions to care plan? D/C care plan? Continue care plan?) Grieving, Anticipatory Related to: Intrauterine fetal loss. Defining Characteristics: Client and significant other express distress about loss (specify for client: e. g., “This can't be happening). Client and signif- icant other exhibit (spec$ denial “The baby is still moving, I can feel her”; anger at staff; or guilt “I shouldn't have done... ” etc. ). Goal: Client and significant other will begin the grieving process by (date/time to evaluate). Outcome Criteria Client and significant other are able to express their grief in a culturally acceptable manner. Client and family are able to share their grief with each other. INTERVENTIONS RATIONALES Assess the client and sig- nificant other's response to the expected loss: denial, anger, bargaining, depres- sion, etc. Client and significant other may present to the hospital in any phase of the grief process. Client may move in and out of the stages. Coping mechanisms assist the client to gradually face the loss. Knowledge assists the client and family to move through their grief. Provide support without offering false hopes (speci- f>. for client: e. g., if in denial, don't force accep- tance of loss; explain that denial is a normal coping mechanism). | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 147 INTERVENTIONS RATIONALES Ensure that all caregivers and auxiliary staff are aware of the client's loss (e. g., sign on door). Support cultural grief behavior of client and fam- ily (e. g., screaming, tearing clothes, etc). Provide for privacy if needed and remain nonjudgmental. Provide clear explanations and instructions. May need to repeat informa- tion. Encourage parents to talk about the baby and their feelings about the loss. Use touch as culturally appro- priate. Allow visitors as client and significant other desire. Encourage parents to name the baby if not already done. Refer to the baby by name. Encourage client and sig- nificant other to see and hold the baby. Clean and wrap infant in warm blan- ket (may apply lotion or powder to infant). Prepare parents for how the baby will look and feel (e. g., bruising, cold, etc. ). Point out attractive characteris- tics of the baby. Allow par- ents to bathe and dress baby if desired. Intervention prevents anguish from well-inten- tioned comments about the baby. Grieving is an individual process influenced by cul- tural norms that may be very different from the nurse's. Client and significant other may be distracted and have trouble concen- trating on information. Encouragement provides permission to grieve together openly. The use of touch has cultural implica- tions. Intervention promotes family support for client and significant other while protecting them from unwanted guests. Naming the baby validates the existence and loss of the child. Seeing and holding the baby validates the birth of a unique individual and the loss. The infant gener- ally doesn't look as bad as the parents might imagine it does. Bathing and dress- ing the baby provides an opportunity to parent the infant before giving it up. INTERVENTIONS RATIONALES Prepare a memory packet for the parents. Include pictures of the baby, foot- prints, a lock of hair if requested, etc. If client refuses packet, file it safely for future requests. Assist parents to make decisions regarding dispos- al of the remains, transfer to a postpartum or gyn room, and early discharge if possible. Provide information about the normal grief process (written and verbal). Discuss gender differences in grieving: e. g., the moth- er has usually formed a longer attachment to the fetus than the fither has. Provide age-appropriate information about helping siblings to cope with their grief. Refer client and significant other to a grief support group (specify for area). Memory items provide tangible evidence of the reality of the baby. Clients may initially reject the packet and then want it later (e. g., on the anniver- sary of the birth). The hospital may be pre- pared to dispose of remains if under 20 weeks. Some funeral homes do not charge for the services to young couples who have a stillborn. Information assists client to understand feelings that may be overwhelming at times. Discussion facilitates open communication between parents to prevent anger or guilty feelings about differ- ences in grieving. Understanding of death varies with age. Ensures that siblings are not for- gotten. Support groups may help client and significant other to cope with loss. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Give example of how client, significant other, and family expressed and shared their grief with each other. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
148 MATERNAL-INFANT NURSING CARE PLANS Spirit oal Dis t less Related to: Perinatal loss. Defining Characteristics: Client expresses feelings of rejection, of disturbance in spiritual belief sys- tem (speci?: e. g,, “How could God do this?”). Goal: Client will experience relief from spiritual distress by (dateltime to evaluate). Outcome Criteria Client will be able to express feelings about belief system and pregnancy loss. Client verbalizes that spiritual needs are being met. Assess client's usual means of expressing spiritual beliefs (e. g. church, yna- gogue, temple, meditation, etc. ). Avoid making assumptions about beliefs. Encourage client and sig- nificant other to express feelings about spirituality related to perinatal loss: anger, doubt, or &lure to find comfort. Reassure client and signifi- cant other that anger and doubt are a common reac- tion to loss. Offer to pray or meditate with client (or ask another caregiver to do this) if desired. Ask client and biiy if &ere are spiritual rituals that may be done for the parents or infant (e. g., infant baptism). Assessment provides infor- mation about the client's beliefs and gives “permis- sion” to talk about these matters. Client and significant other may feel that it is ~nappropriate to discuss these feelings. Encouragement facilitates identification of feelings. Client and significant other may feel guilty about being angry or having doubts. Prayer or meditation may help the client to seek spir- itual assistance. Baptism may provide com- fort for dients be~ongi~g to certain religions. Rituals may include bathing the infant, chanting, etc. IN'XXR~NTIONS RATIONALES Contact the client's spiritu- al advisor or pastoral care department if client desires. A spiritual advisor may offer support and comfort to the client and family Evaluation (Rateltime of evaluation of goal) (Has goal been met? not met? partially met?) (Is client able to express feelings about belief sys- tem? Does clienr indicate that spiritual needs are being met? Specify: e,g., talked with pastor, memorial service planned, etc. ). (Revisions to care plan? DIC care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 149 PGEz ripening agents oxytocin Emotional Response (Kubler-Ross Stages of Grieving) Denial Depression Acceptance | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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POSTPARTUM 151 UNIT 111 e POSTPARTUM Healthy Puerperium Basic Care Plan: Vaginal Birth Basic Care Plan: Cesarean Birth Basic Care Plan: Postpartum Home Visit Breast-Feeding Postpartum Hemorrhage Episiotomy and Lacerations Puerperal Infection Venous Thrombosis Hematomas Adolescent Mother Postpartum Depression Parents of the At-Risk Newborn | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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POSTPARTUM 153 Healthy Puernerium The puerperium, or postpartum period, begins physiologically with the birth of the baby and lasts for approximately six weeks. During this time the maternal reproductive organs recover from preg- nancy and ovulation may return in non breast- feeding mothers. Psychological adjustment to the birth of a new baby certainly may take longer than six weeks. Sometimes a “fourth trimester” is described to include mental and emotional adap- tation as well as the physiologic recovery from childbirth. Physical Changes Uterine Involution: The uterus contracts after expulsion of the placenta to prevent hemor- rhage from the placental site. After the first 24 hours, the uterine fundus J( one cm/day until it is no longer palpable above the symphysis pubis at 10 days. Endometrial Regeneration: Restoration of the endometrium takes 3 weeks except at the pla- cental site, which takes up to 6 weeks. Lochia: rubra (2-3 days), serosa (7-10 days), Perineum: Usually redness and edema are pre- sent afier birth. May have an episiotomy, lacer- ations, bruising, or hematomas. The urethra may be edematous. and alba (1-2 weeks, or up to 6 weeks). Breasts: Engorgement (venous and lymphatic congestion) occurs on about the third day afier delivery. Secretions change from colostrum to milk on about the third to fifth day after birth. Fluid Balance: Client exhibits characteristic diuresis and diaphoresis as fluid moves from the extravascular spaces back into circulation. Cardiovascular: Loss of < 500 cc blood for vagi- nal birth, < 800 cc for cesarean birth is com- pensated for by loss of placental circulation and 4 uterine circulation. An f' C. O. due to the fluid shifi may cause J( pulse. B/P should remain WNL. GI: Hunger and thirst are common after birth. Decreased GI motility, perineal or hemorrhoid discomfort may lead to constipation. lab Value Changes I Hgb/Hct I 9 1 4-6weeks I Psychologlcal Changes Attachment and bonding behaviors: eye con- tact, touch, enfolding, talking/smiling, and identification process. Taking-In Phase: Mother relives birth experi- ence, focuses on own physical needs, dependen- cy on others. Taking-Hold Phase: Client is more indepen- dent, focuses on caring for self and infant, needs education and reassurance that she is capable. Maternal Role Attainment: Client moves from the idealized fantasies during pregnancy to try- ing to care for infant as others advise, to inde- pendent decisions regarding parenting. Up to 80% of new mothers experience “Postpartum Blues”: depression and emotional lability associated with unexpected crying, feel- | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
154 MATERNAL-INFANT NURSING CARE PLANS ing overwhelmed. Occurs within the first week and lasts no more than 2-3 days. Should be dif- ferentiated from postpartum depression. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 155 Cultural Diversity All cultures have beliefs related to maternalhnfant care after childbirth. The nurse should ask the client about her individual cultural beliefs to avoid stereotyping. Assessment of the following areas may reveal cultural prescriptions and prohibitions. Activityl Rest no activity restriction, rooming-in desirable, rest when the baby does, avoid rooming-in, someone else cares for baby while mother rests and bedrest under several blankets for 7 days to 3 months female relatives or hired women help with baby activity may be restricted up to 40 days father helps at home, PP exercises regains her strength Nutrition Hygiene Safety Spirituality increase calories and calcium for lactation; otherwise, lose weight gained eat and drink only foods/liquids considered “hot” and avoid those considered special traditional foods may be indicated (e. g., seaweed soup, steak dinner) shower and hair washing as soon as possible avoid cold air or water; no showers avoid bathing until lochia stops don't wash hair for one week; wear head covering for warmth infant car seat; infant sleeps in crib, not with mother avoidance of evil influences: no praise of infant, don't touch infant's head, infant sleeps with mother, carried close to body infant Baptism/Christening, Bris naming ceremony (may be named after someone special) rituals performed by father burial/burning of placenta during pregnancy ''cold'' (not necessarily related to temperature or spices) use of talismans/protective objects Other Infant Care Breast-Feeding. breast offered at birth, feed on demand, avoid formula supplements colostrum discarded, infant fed sugar-water or honey and water until infant dressed in diaper and shirt, loose blanket infant tightly wrapped, belly-binder applied milk comes in (3-5 days) cigars, flowers, balloons, announcements men are excluded from birth or contact with lochia desired visitors include family, friends, neighbors freely ask for pain medication and information avoid complaining or showing pain, avoid eye contact avoid asking questions and bothering the staff | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
156 ~TE~~-INF~T NURSING CARE PLANS Postnartum Care Path: Uaoinal Birth Assessments Tp R, B/P OB 4 ql S” X 4 Bj P, P, fisndus, Ida, perineum hemorrhoids breast assessment bladder-d epidural catheter removed ~nd~g: eye contact/ touch TPR OB 4 q 30“ X 2 thenq 1 hr X2 empty bladder q 4hr (vo~d/~t~eter~ leg movement 8a sensation infant handling attachment TPR, Homan's sign, breast as~s~ent ~OB4qs~tif WNL bladder d after void x 2 or until WNL I H&H bowel movement v/s, OB 4 WNL elimination WNL infant/self-care adequate Teaching nmd newborn ~~idi~ infant bulb syringe breast-feeding: rooting, latching on, removing, frequency infant security answer all questions handwashing pericare peri meds fundus/lochia nursing: bmst me nutrition t fluids bottle feeding: burping, positioning breast care self-care nutrition activityjrest e~~~ation infant care: cord, bathing, circ. care, safety, immunizations Unit phone # and written instructions given warning s/s reviewed infant 8b self-care reviewed contrace~t~on, PP exercises, PKU, 86 immunizations, reviewed W pitocin ice pack to perineum X 8 hr analgesics pn d/c N pm Tucks, peri- spray stool softener m UV sits bath heat prescriptions given enerna or stool softener pm Other diet as tolerated with snacks motherlbaby I1 ambulate with assistance to BR OB Gift Pack activity as tolerated- shower pm Iactation specialist prn social services WIC Prn car seat mother/ baby a~~in~ent$ referral for home visit | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 157 Postmarturn Care Path: Cesarean Birth 1“ hour 4 hours 8 hours le PP day 2nd PP day 3“ PP day --Discharge Assessments N, foky temp, MC, pain, I&U Ei P, P, R, Sa OZ dsg CD&l fundus Jlachia q S”X4 q 15” X 2 q30” X 2 qlh X2 bonding! eye contact/ touch B/P, T, P, R, dsg CDM fundus Jlochia q4h X2 LOC, MAEE bowel sounds B/P, T, p, R, f~dus/lochi~ dsg CD&I bowel sounds Hornan's sign, breast assessment and bonding 1860 1 9 8h bladder 4 q 4h (catheterize pm) HLH i bladder 4 after void X 2 or until WNL assess €or BM assess infant and self-care v/s, UB 4 WML incision CDM elimination WNL infant/self-care adequate Teaching pain relief TCDB, splinting normal newborn answer all questions I holding infant bulb syringe ~~dwa~~g pericare f~~dus/l Qchi& infant security I breast-feeding: rooting, l&~~hjn~-~~, removing, frequency, breast care bottle feeding: positioning, burping, breast care self-care: nutrition, body mechanics activity,hest elimination infant care: cord care bathing, circ care, safety, ~rn~~~~tions incision care review infant and aelf- Unit phone # and written instructions given warning s/s reviewed infant/ self-care, contraception, PKU, and immunizations reviewed l Keds/Tx IV with pitocin pain relid i M, pericare f d/c Wprn d/c foleyprn pa. pain meds Rubella prn remove dsg prn staples removed steri-strips prescriptions given enema or stool softener pm Other mother/baby ID sips 8k chips or DAT with snacks up with assistance I CL liquids or DAT with snacks ambulate with assistance lactation specialist prn regular diet with snacks ambulate w/o assistance shower pm car seat motherlbaby appointments referral for home visit | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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POSTPARTUM 159 Basic Care Plan: Uaginal Birlh The nursing care plan is based on a thorough review of the prenatal record, labor and delivery summary, and continuing postpartum assess- ments. Individual data should be inserted whenev- er possible. Nursing Care Plans Infiction, Risk for (165) Related to: Site for invasion of microorganisms (specify: e. g., episiotomy, lacerations, catheteriza- tion, etc. ). Pain (166) Related to: Tissue trauma and edema afier child- birth, uterine contractions (after-pains), engorged breasts, etc. Defining Characteristics: Client reports pain (specify site and type of pain, rating on a scale of 1 to 10 with 1 being least, 10 most). Client is (specify: e. g., grimacing, crying, guarding, request- ing pain meds, etc. ). Additional Diaanoses and Plans Fluid Volume Dt$cit, Risk for Related to: Active losses after childbirth (vaginal or cesarean), inadequate intake. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client will not experience a fluid volume deficit by (dateltiine to evaluate). Outcome Criteria Client's pulse is < 100, B/P > (specify for client), mucous membranes moist and pink, fundus is firm with moderate-small amount of lochia. INTERVENTIONS RATIONALES Assess client's hx for risk factors for hemorrhage (e. g., long labor, use of pitocin, overdistended uterus, clotting problems, etc. ). Assessment provides infor- mation about client's risk for puerperal hemorrhage. Assess client's B/P, P, & R (specify frequency). Assess uterine tone, posi- tion, and color and amount of lochia; observe for hematornas and integrity of incisions or dressings (specifj fiequency). Massage the uterus if boggy, guarding over the symphysis pubis. Do not overstimulate. Administer uterotonic drugs as ordered (specie: drug, dose, route, time). Encourage frequent emp- tying of the bladder at least q 4h (catheterize prn as ordered). Estimate blood loss by counting or weighing peri- pads. Soaked pad in 15 min is excessive. I gm = 1 cc if weighing pads. Hypovolemia results in 4 BIP; the body compensates by vasoconstriction and f'l? 6 volume leads to less available oxygen and 9 R. Assessments provide infor- mation about uterine dis- placement and tone, vagi- nal blood loss, hidden bleeding, and wound dehiscence. Massage stimulates uterine contraction. Guarding pre- vents uterine prolapse. Overstimulation may cause uterine relaxation and hemorrhage. Speci Fy action of drug ordered (e. g., oxytocin, ergotrates, and prostaglandins). Bladder distension may displace the uterus up and to a side causing 4 tone and f' bleeding. The degree of blood loss may not be apparent from appearance of vaginal dis- charge. Estimate helps determine replacement requirements. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
160 MATERNALINFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Assess intake and output (specify frequency). Assess skin color, temp, turgor, and moisture of lipslmucous membranes (specify frequency). Monitor lab results as obtained (specify: e. g., Hgb, Hct, urine sp. gravi- ty, clotting studies, etc. ). Inform caregiver of any signs of unusual bleeding (e. g., from injection sites, gums, epistaxis, or petechi- ae). Initiate and maintain IV fluids and blood products as ordered (specify fluids and rate). Encourage p. 0. fluid intake (specify culturally appro- priate types and amounts) if allowed. Notify care giver if bleed- ing continues after nursing interventions. Assessment of intake and output provides informa- tion about fluid balance. Pale, cool skin, poor skin turgor, and dry lips or membranes may indicate fluid lossldehydration. Monitoring provides infor- mation about fluid loss. Increased urine specific gravity may indicate J, fluid. Hgb and Hct indi- cate the extent of blood loss. Clotting studies indi- cate the client at Ip risk for hemorrhage. Bleeding from unusual sites may indicate a clot- ting abnormality. Intervent ion provides replacement of fluid or blood losses. Encouragement promotes fluid replacement for loss- es. Some cultures prefer hot liquids after childbirth and may avoid cold drinks. Continued blood loss may indicate retained placental fragments or a cervical lac- eration requiring medical treatment. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What is client's pulse? B/P? Are mucous mem- branes moist and pink, fundus firm with moder- ate-small amount of lochia? Specify findings. ) (Revisions to care plan? D/C care plan? Continue care plan?) Spiritual Well-Being: Enhanced Potential for Related to: Life-affirming experience of childbirth and motherhood. Defining Characteristics: Client reports spiritual well-being (specify: e. g., “There must be a God,” “This gives meaning to my life,” etc.-does not need to be religious in nature). Client exhibits a sense of awareness, inner peace, and trust in rela- tionships with infant and family (provide exam- ples). Client offers prayers of thanksgiving. Goal: Client will continue to experience spiritual well-being by (datehime to evaluate). Outcome Criteria Client expresses continued feelings of spiritual well-being. Client exhibits nurturing behaviors towards infant. INTERWNTIONS RATIONALES Assess client's perceptions about the experience of giving birth. Offer accurate information if client has questions about the experience. Assess client's religious preferences or any desired spiritual practices that are related to childbirth. Facilitate religious or spiri- tual practices as indicated (specify for client). Assessment provides infor- mation about client's per- ceptions. Information assists the client to construct an accu- rate birth story. Assessment provides infor- mation about the client's spiritual needs. Client and family may have special requests (e. g., a timelplace for a ceremo- ny, the placenta for burial, etc. ). | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 161 INTERVENTIONS RATIONALES Contact client's spiritual advisor or hospital pastoral care if client wishes. Observe client's nurturing behaviors towards inknt. Intervention ensures that client has access to a spiri- tual advisor if she wishes. Spiritual well-being pro- motes love and commit- ment towards others. Inexperienced clients may need assistance with infant-care skills. Praise reinforces nurturing of the infant and enhances Offer assistance and expla- nations as needed about caring for the infant. Praise client for her nur- turing and skill with infant care. client's self-esteem. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does client report feelings of spiritual well-being? Does client nurture her infant? Specify client's activities. ) (Revisions to care plan? D/C care plan? Continue care plan?) Knowledge Deficit: Infant and Self-care Related to: Limited experience and skill in provid- ing infant care and self-care after giving birth. Defining Characteristics: Client is a primipara (or first time to breast-feed, etc. ). Client expresses need for information about self-or infant care (specify). Client reports inaccurate perceptions about self-or infant care (specify). Goal: Client will gain cognitive knowledge and psychomotor skills needed for self-and infant care by (dateltime to evaluate). Outcome Criteria Client verbalizes understanding of self-care and infant care instruction. Client demonstrates psy- chomotor skills needed for infant and self-care. INTERVENTIONS RATIONALES Assess client's previous experience with childbirth or caring for a newborn infant. For clients who have expe- rienced childbirth before, ask if they have any ques- tions about infant or self- care. Review current infor- mation with client. Teach client as nursing care is provided and rein- force with videos, follow- up instruction, and written materials (if client is liter- ate). Obtain the services of an interpreter as needed. Include significant other and family in teaching. Teach client about uterine involution, fundal tone, and lochia. Instruct in per- ineal care, handwashing, use of peri-bottle, wiping from front to back, correct application of pads, avoid- ing sex, tampons, or douches per caregiver instructions. Teach cesarean clients to care for incision per care-giver instructions (specify). Teach signs and symptoms of infection to report. Teach client to care for infant: demonstrate use of bulb syringe, safety and nurturing for the infant and holding, feeding, burping, diapering, cir- cumcision care (if indicat- ed), cord care, bathing, how to take a temperature, Assessment provides infor- mation about client's cur- rent knowledge base and experience. Clients may have had diffi- culty in prior experiences with infant or self-care. Reviewing material with multiparous clients ensures that accurate information is provided. Varied teaching methods facilitate learning by addressing client's individ- ual learning style. Repetition and inclusion of the family may be help- ful as the client experiences increased sensory input during the puerperium. Instruction aids the client in gaining skills and knowledge needed for self- care. Interventions remove pathogens from the hands, cleanse the perineum, and prevent trauma and fecal contamination of per- ineum. Information assists the client to care for incision, prevent infection, and pro- mote healing. Instruction promotes con- fidence for the mother as she gains skills. Observation and reinforce- ment ensure appropriate technique. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
162 MATERNALINFANT NURSING CARE PLANS INTERVENTIONS RATIONALES and when to call the doc- tor. Observe client as she cares for infant and rein- force positive attempts. Instruct client in breast care. For non-nursing mothers teach to wear a snug bra, avoid stimula- tion of the breasts and to use ice packs (frozen peas) or mild analgesics as ordered for discomfort. Reassure client that dis- comfort should subside in a day or two. Teach breast-feeding mothers to wash their hands before feeding, wash their breasts without soap, wear a support bra, and inspect the nipples for pain or sores after each feeding. Teach client to continue PW, drink 8-10 glasses of watedday, and eat a nutri- tious diet. Use the food guide pyramid to plan a culturally acceptable diet including fresh fruits and vegetables, fiber, protein, and vitamin C. Provide information for breast- feeding mothers about extra fluids and dairy products needed (specify). Teach client to avoid stren- uous activity or exercise for six weeks. Provide infor- mation from caregiver about postpartum period exercises. Encourage client to obtain adequate rest during the puerperium. Teach her that Information helps the client to avoid activities that may stimulate the breasts and cause increuse:d discomfort from engorge- ment. Information helps the client to avoid infection or drying of the nipples. Information helps the client to plan for adequate nutrition for recovery from childbirth. Fresh fruits, vegetables, and added fiber help prevent constipation. Protein and vitamin C enhance tissue healing. Nursing mothers require extra calories and fluids to produce milk and meet their own needs. Strenuous exercise may cause postpartum hemor- rhage before the placental site is healed. Exercise helps the client's body return to its pre-pregnancy shape. Client may try to do too much, delaying healing and risking exhaustion. INTERVENTIONS RATIONALES activity that leads to an increase in the flow of lochia is a sign that she needs to slow down. Demonstrate respect for client's cultural prescrip- tions and prohibitions regarding postpartum care. Teach client about the return of menstruation and ovulation. Inform about the possibility of becoming pregnant and assist her to make contraceptive choic- es. Teach client about any medications that are pre- scribed for her after dis- charge. Instruct breast- feeding moms to avoid taking medications with- out checking with the baby's caregiver first. Provide information about and phone numbers for local support groups (spec- ify: e. g., La Leche League, Mothers of Twins, etc. ). Teach client about use of infant car seat, need for follow-up PKU, and infant immunizations. Provide written and verbal information about danger signs to call the primary caregiver: fever, chills, f' bleeding, foul smelling lochia, 9 incision, breast or leg pain, wound dehis- cence, or burning on uri- nation. Observe client's self-care and infant care ability dur-Client may need “permis- sion” to rest. Cultural respect avoids conflicts about care that may make the client feel guilty. Knowledge helps the client to understand how her body works and to make personal decisions about family planning. Specify action, dose, route, and indications for any prescribed medications. Most drugs distributed by the blood are also found in the breast milk. Support groups may offer increased information about topics of special interest to the client. Information promotes infant safety. Information assists the client to seek immediate care for puerperal compli- cations. Observation provides information about client's | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 163 INTERVENTIONS RATIONALES ing hospitalization. Refer client for additional assis- tance as needed (specify: e. g., home visit). Discuss the need for Rh immune globulin (Rho GAM) with Rh nega- tive clients. Provide blood type card. Review and reinforce all teaching at discharge. Provide client with a phone number to call for questions after she gets home. ability to care for herself and her baby after dis- charge. Referral provides additional education. Rh-negative clients should understand the need for Rh immune globulin after miscarriage or birth of an Rh-positive baby to pre- vent isoimmunization of future infants. Intervention promotes access to continued infor- mation after client is dis- charged. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does client verbalize understanding of self-care and infint care information? Does client demon- strate psychomotor skills needed for self-and infant care? Specify. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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POSTPARTUM 165 Cesarean Birth The nursing care plan is based on a thorough review of the prenatal record, labor and delivery summary, operative records, and a continual post- partum assessment. Individualized data should be inserted wherever possible. Nursing Care Plans Fluid blurne Deficit, Risk for (159) Related to: Excessive fluid losses secondary to operative delivery. Inadequate intake for needs. Spiritual Well-Being: Enhanced Potential for (I 60) Related to: Life-affirming experience of giving birth. Defining Characteristics: Describe client and sig- nificant other's response to birth (e. g., quotes related to spiritual dimension of the experience). Specie nurturing and loving behaviors of client and significant other towards infmt. Knowledge Deficit: Inf Alnt and Self-care (IGI) Related to: Limited experience with infant and self-care (specify: e,g., first baby, first cesarean birth, etc. ). Defining Characteristics: Client expresses lack of knowledge about self-and infant care after birth (specify). Client verbalizes incorrect information about self-or infant care (speci?). Additional Diaanoses and Plans Infection, Risk for Related to: Site for microorganism invasion sec- ondary to childbirth and/or surgical interventions. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client will not experience signs of infection by (datehime to evaluate). Outcome Criteria Client's temperature is < 100. 4" F, P < 100, inci- sion is dry and intact, edges well-approximated without redness or edema, no foul-smelling lochia or pelvic pain. INTERVENTTONS RATIONALES Wash hands before and &er caring for client; use gloves when indicated; don't share equipment with other units. Assess client's temperature, B/P, P, and R (specify fre- quency). Notify caregiver if temp is 100. 4" F after the first 24 hours, or if pulse is consistently >loo. Teach surgical clients to TCDB and encourage ambulation. Instruct in leg exercises while in bed. Assess dressings or inci- sions (specify frequency) noting if dressing is clean, dry, and intact, if incisions exhibit redness, edema, ecchymosis, drainage, and approximation (REEDA). Assess client for increased abdominal tenderness dur- ing fundal checks. Instruct client to report continuous pelvic pain. Interventions help prevent the spread of pathogens between staff and patients. Assessment provides infor- mation about developing infection: temperature may be slightly f early due to dehydration from labor. Slight J, P is common after birth and tachycardia may indicate infection. Teaching helps gain client compliance to prevent pul- monary stasis that may lead to infection. Assessment provides infor- mation about developing infection: Local inflamma- tory effects cause redness and edema. This may be followed by purulent drainage and wound dehis- cence. Assessment provides infor- mation about inflamma- tion of the endometrium. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
166 MATERNAJ,.,-INFm T NURSING G4R. E PLANS INTER~NTIONS RATIONALES Note color, odor, and con- sistency of lochia. Instruct client to report foul- smelling lochia. Provide catheter care per agency protocol. Keep catheter bag below the level of the bladder and off the floor. Use aseptic tech- nique to obtain specimens. Teach client to perform peri care after elimination and to change peripads fre- quently, applying snugly from front to back. Encourage client to void every 4 hours. Assess blad- der emptying (speci Q fre- quency). Catheterize only as needed employing ster- ile technique. Instruct client to report any burn- ing or pain with urination. Obtain specimens as ordered (specify: e. g,. urine specimens, wound cul- tures). Monitor lab results. Inspect IV sites per agency protocol. Note redness, warmth, pain, or edema. Discontinue or change site as indicated. Administer antibiotics as ordered (specify: drug, dose, route, times). Encourage clients with an episiotomy to take sitz baths as ordered (specify). Ensure that tub is cleaned Foul smelling or purulent lochia signals infectious processes. Lochia has a characteristic odor some- what like menstrual dis- charge. Interventions keep the opening to the urethra clean, prevent urine back- flow and contamination of catheter bag. Teaching helps client keep the perineum clean and dry. Warm, moist environ- ment facilitates the growth of microorganisms. Postpartum diuresis may cause over-distention or incomplete emptying of the bladder. Urinary stasis provides a medium for growth of microorganisms. Burning and pain are signs of inflammation associated with UTI. Laboratory examination of specimens is indicated to determine the causative organisms and their sensi- tivity to antibiotics. Inspection provides infor- mation about the develop- ment of inflammation and infection at invasive sites. Specify action of each drug given. The moist heat from a sitz bath increases circulation to the perineum and facili- tates healing. Cleaning or INTERVENTIONS RATIONALES before each use or use individual disposable tubs. cross-contamination. individual tubs prevent Maintain a clean environ- ment. Ensure that client's room and bathroom are microorganisms. cleaned frequently and appropriately. A clean environment may discourage the growth of Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What is client's temperature? pulse? Are incisions dry and intact, edges well-approximated, without redness or edema, no foul-smelling lochia or pelvic pain?) (Revisions to care plan? D/C care plan? Continue care plan?) Pain Related to: Tissue trauma secondary to surgery, perineal trauma from vaginal birth, uterine invo- lution; engorged breasts, Defining Characteristics: Client complains of pain (specify using quotes). Client rates pain on a scale of 1 to 10 (specify). Client is grimacing, guarding painfiil area, etc. (specify). Goal: Client will experience a decrease in pain by (dateltime to evaluate). Outcome Criteria Client rates pain as less than (specify) on a scale of 1 to 10 with 1 being least, 10 being most. Client appears calm, no grimacing or guarding of area. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 167 INTERVENTIONS RATIONALES INTERVENTIONS RATIONAWES Assess client's pain using a scale of 1 to 10 with 1 being least, 10 being most (specify frequency). Observe client for nonver- bal signs of pain: grimac- ing, guarding, pallor, withdrawal, etc. (specify frequency). Assess location and charac- ter of pain each time the client reports discomfort. Notify caregiver if unusual pain develops. Instruct client to use an ice pack for 8 hours after birth as ordered. Keep pack 213 full of ice. Administer appropriate pain medication as ordered (specify: drug, dose, route, times). Assess client for pain relief within an appropriate time afcer medication adminis- tration (specify for drug). Observe client for adverse effects of drug (specify for drug given). Instruct clients receiving regular pain medication to ask for the drug before pain becomes unbearable. Teach client about the physiology of her discom- fort (specify for client: e. g., afier-pains when breast- feeding are caused by stim- ulation of oxytocin release and uterine contraction). Assessment provides objec- tive measurement of the client's perception of pain. Observation helps identify discomfort when the client doesn't ask for help. Cultural variations may govern the expression of pain. Assessment provides infor- mation about the cause of pain. Unusual pain may indicate complications. Application of ice decreas- es edema and provides a local anesthetic effect. Specify action of specific drug and rationale for choice. Assessment provides infor- mation about client's response to peak levels of drug. Observation allows early detection and treatment of adverse effects. Pain medication is more effective and lower doses are needed if given before pain becomes severe. Knowledge may +b the anxiety associated with unfamiliar pain. Teach client nonpharma- cological pain relief mea- sures: positioning to avoid pressure on painful areas; splinting of incision; tight- ening buttocks before sit- ting to prevent traction on perineum; wearing a snug bra, if non-nursing; ensur- ing the infant is latched on and removed from the breast correctly if breast- feeding, etc. Assist client to take a sitz bath if ordered (specify type available and method to use). Instruct client to use the sitz for approxi- mately 20 minutes 3-4 times a day. Teach client to perform Kegel exercises (suggest frequency). Teach client correct use of products ordered for relief of episiotomy or hemor- rhoid pain (specify: e. g., anesthetic ointments, sprays, or witch hazel pads). Teach client to eat fresh fruits and vegetables, and whole grains daily and to drink 8-10 glasses ofwater. Administer stool softeners as ordered (specify). Encourage ambulation as soon as possible after birth. Evaluate client for develop ment of pain in the lower extremities (Homan's sign). Teaching provides the client with information about self-care activities to decrease pain. Interventions decrease pressure on painful areas and incisions. Painful nip- ples may be caused by inadequate latching-on. Moist heat from the sitz bath promotes comfort and healing by increasing circulation to the per- ineum. Kegel exercises promote perineal circulation and healing. Specify action of medica- tions ordered. Teaching provides infor- mation the client needs to make diet decisions that will help prevent constipa- tion. Stool softeners help decrease pain from bowel movements when client has a 4th laceration or episiotomy. Ambulation decreases venous stasis. Venous stasis and I' platelets at birth lead to potential develop- ment of thrombophlebitis. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
168 MATERNAL-INFANT NURSING CARE PLANS INTERVFi NTIONS RATIONALES Encourage client to plan frequent rest periods in the first few postpartum tress. weeks. Teach relaxation techniques as needed. Fatigue may add to per- ceptions of pain and dis- Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What does client rate pain on a scale of 1 to lo? Does client appear calm? Is client grimacing or guarding body areas?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 169 Postnartum Home Visit The postpartum home visit enables the client to receive additional assessment and instruction in the comfort and reality of her own home. Many questions about self-and infant care arise once the mother has been discharged. The care plan is based on a thorough review of the client's records and assessments made in the home. Nursing Care Plans Knowledge Deficit: Infant and Self-cure (IG) Related to: Inexperience and limited information about infant and self-care after childbirth. Defining Characteristics: Client verbalizes lack of knowledge or misunderstanding about infant and/or self-care (specify using quotes). Client exhibits incorrect self-or infant care techniques (specify). Furnib Coping: Potential for Growth Related to: Adaptation of family to new family member. Defining Characteristics: Family members are involved in care of the mother and newborn. Family members verbalize positive reactions to addition of a new family member (specie). Goal: Family will continue to experience growth in coping with the stresses of a new baby by (datdtime to evaluate). Outcome Criteria Family members express positive feelings about their new baby and new roles in the family (other specifics as indicated). INTERVENTIONS RATIONALES Identify family structure and encourage members' participation in home visit. Assess family members' verbal and nonverbal responses to the new baby. Assess the infant's sleeping and eating patterns and how these affect family members. Praise effective coping mechanisms used by the family (specify). Discuss infant growth and development with the fam- ily. Point out infant reflex- es and attachment behav- iors. Refer family to support groups as indicated (speci- fy). Family may include grand- parents or friends in addi- tion to the nuclear family. Birth of a new family member alters each mem- ber's role in the family. Frequent infant feeding and lack of sleep are stres- sors for new families. Praise reinforces the fami- ly's effective coping with the stress of a new baby. Discussion provides antici- patory guidance for family to facilitate infant growth and development. Support groups may rein- force positive coping. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Do family members report positive feelings about their new baby and their changed roles in the family? Specify. ) (Revisions to care plan? D/C care plan? Continue care plan?) Futigue Related to: Demands of caring for newborn while recovering from childbirth. Defining Characteristics: Client states she is exhausted (specify). Client states she doesn't have enough energy to accomplish desired tasks (speci- fy: e. g., fix dinner, care for other children, etc. ). | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
170 MATERNAL-INFANT NURSING CARE PLANS Client appears lethargic, has dark circles under eyes, etc. (physical signs of fatigue). Goal: Client will experience less fatigue by (datehime to evaluate). Outcome Criteria Client identifies priority activities that she will focus on during the postpartum period. Client and family identify tasks that family members will be responsible for. INTERVENTIONS RATIONALES Assess client's current rest and activity patterns. Assist client to identifjr pri- mary cause of fatigue (e. g., worry, lack of sleep at night, etc. ). Discuss physiologic factors that increase fatigue during the puerperium: long labor, cesarean birth, epi- siotomy pain, and anemia. Assess client for postpar- tum complications; exces- sive bleeding or signs of infection: fever, malaise, redness, edema, purulent drainage from incisions, pelvic pain or foul- smelling lochia. Notifj. caregiver. Help client express frustra- tion related to infant care and fatigue. Provide emo- tional support and reassur- ance. Assess client for signs of postpartum “blues” or Assessment provides infor- mation about adequacy of client's rest and activity pattern. Client may be too tired to identifjr primary problem without some assistance. Understanding the physio- logic basis of fatigue helps the client plan self-care activities to J, fatigue. Excessive bleeding may cause anemia and fatigue related to insufficient hemoglobin. Signs of infection also include fatigue. Facilitating expression feelings validates the client's experience. of A short-lived period of depression accompanied by INTERVENTIONS RATIONALES depression. Discuss hor- monal changes, role changes, and exhaustion as precipitating factors. Discuss situational factors that increase fatigue (e. g., small children to care for, lack of social support sys- tem, beliefs about house- keeping, difficult-to-con- sole infant, etc. ) Assist client and family to identify strengths they can use to cope with current increased demands. Reassure family that expressed feelings are com- mon and that most fami- lies adjust by 6 weeks post- partum. Assist client and family to identify priority activities (e. g., mother and infant care, eating, sleeping) and those which may be delayed (e. g., cleaning, social responsibilities). Assist client and family to identifjr tasks that each member can be responsible for (specify for ages of children). Encourage the client to rest or sleep when the infant is sleeping. Teach relaxation tech- niques, mental imagery, or meditation to help cope with tension. Assess current diet and encourage client to ingest emotional fragility is com- mon in the first few weeks postpartum. Conrinued depression needs further investigation. Discussion helps client and family identify factors that increase fatigue. The family may have unexpected resources and strengths. Reassurance helps decrease anxiety and associated fatigue. Identification of priorities helps the family to deter- mine essential and non- essential tasks. Delegation allows the client to focus only on essential activities. Encouragement gives the client permission to nap frequently. Anxiety produces increased psychological demands and reduces energy. Poor nutrition and dehy- dration add to feelings of | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 171 INTERVENTIONS RATIONALES recommended amounts of calories, protein, vitamin C, and fluids. fatigue. Protein and vita- min C are needed for tis- sue regeneration after childbirth. Client may have inade- quate financial means or support system to cope with postpartum stresses. Refer client for additional assistance as indicated (e. g., WIC, counseling, community services, etc. ). Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What are the priority tasks the client identified? Which tasks did client and family identify that family members will be responsible for?) (Revisions to care plan? D/C care plan? Continue care plan?) Nutrition, Altered More Than Body Requirements Related to: Intake in excess of that required for metabolic needs. Defining Characteristics: Client verbalizes a desire to lose excessive weight gained during preg- nancy (specify client's current weight and pre- pregnancy weight or ideal weight). Client reports eating habits that are in excess of current needs (specify: e. g., high in calories and fat, low in fruits and vegetables). God: Client will ingest and appropriate diet by (datehime to evaluate). Outcome Criteria Client identifies excesses in current diet. Client plans a diet to meet nutrition and metabolic needs. INTERVENTIONS RATIONALES Assess client's weight. Compare to pre-pregnancy weight and ideal weight for height and build. Encourage client to con- tinue taking PNV as ordered during puerperi- um. Describe normal weight loss after childbirth: the average mother loses 10-12 LB at birth followed by average weight loss of 1 to 1 $ LB/week during the following 6 weeks. Inform the client that she should not attempt to diet while breast-feeding. Nursing clients will usually lose weight faster due to metabolic needs of lacta- tion. Assist client to review cur- rent eating habits using a 24-hour diet recall and a copy of the food guide pyramid. Provide client with a copy of the food guide pyramid and suggested diets for weight loss after child- birth. Assist client to plan a nutritious diet for her fam- ily that incorporates cul- tural preferences and financial ability. Help client to plan how to reduce her own calories by 300/day. Include necessary nutrients without added fats or empty calories. Assessment provides infor- mation about appropriate weight for individual client and evaluation of possible excessive weight gain dur- ing pregnancy. Supplements replenish vit- amin and iron supplies decreased by pregnancy and birth. Client may have unrealistic expectations about weight loss after giving birth. Nursing mothers require increased calories to pro- duce milk. Breast-feeding increases metabolism and usually weight loss as well. Review provides informa- tion about current intake compared to nutritional needs. Visual aids and reading materials provide the client with a source of continued information at home. Assistance ensures that cor- rect foods are chosen while empowering the client to make her own plan. Generic diets may not be affordable, include cultur- ally preferred foods, or be appropriate for the whole family. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
172 MATERNAL-INFANT NURSING CAW PLANS INTERVENTIONS RATIONALES-~ ~ Discuss the need for exer- cise as well as dietary mod- ification to lose weight. Encourage client to begin with daily walking and exercise program with advice of her caregiver. weeks. Refer client to a dietitian as indicated (specify: e. g., diabetic moms, clients with unusual diets or spe- cial needs). Walking is generally an appropriate postpartum exercise. The client should avoid strenuous exercise until the placental site has healed at approximately 6 A dietitian is specifically prepared to advise clients with numerous or unusual nutrition questions. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What excesses did the client identify in her diet? What diet plan did the client make to meet nutri- tional and metabolic needs?) (Revisions to care plan? D/C care plan? Continue care plan?) Sexuality Patterns, Altered Related to: Effects of childbirth on sexual behav- io r. Defining Characteristics: Client reports negative perceptions about sexuality after childbirth (speci- f>. : e. g., “My husband is hounding me to have sex and I don't want to” or “I'm really afraid that it's going to hurt”). Client reports lack of interest in sexuality. Client reports concern about sexual feel- ings during breast-feeding (specify). Goal: Client and partner will report satisfactory patterns of sexuality by (datehime to evaluate), Outcome Criteria Client and partner will verbalize understanding of postpartum physiologic changes affecting sexuali-ty. Client and partner will identify ways to meet sexual needs during the puerperium. INTERVENTIONS RATIONALES Establish rapport with the client and partner (if avail- able). Provide privacy for discussion of sexuality. Offer general information about reproductive con- cerns and sexuality after childbirth. Elicit questions. Identify the need to abstain from sexual inter- course (as advised by care- giver) until the placental site has healed (lochia has stopped and perineal inci- sions or lacerations are healed: usually 3-4 weeks for vaginal birth) to avoid infection or trauma. Discuss postpartum physi- ology that may interfere with sexuality: fatigue, vaginal and perineal sore- ness, lack of lubrication until ovulation recom- mences, and breast tender- ness. Assist client and partner to identi6 ways to meet sexu- al needs during the puer- perium (suggest other forms of expression of affection, varied positions, use of water-soluble lubri- cants, etc. ). Reinforce the understand- ing that subsequent preg- nancy is possible even Client and partner may feel uncomfortable dis- cussing sexual concerns in front of anyone else (e. g., children). Offering general informa tion allows the client and partner to ask questions they may have been too shy to bring up. Client and partner may not understand the ratio- nale for abstinence in the immediate postpartum period. Many couples resume sexual relations before the six-week post- partum visit. Information decreases unwarranted anxiety about altered sexuality related to physiologic changes during the puerperium. Assistance empowers client and partner to adapt to transient physiologic changes while providing information about possible solutions. Client may believe that she can't get pregnant if she's breast-feeding or until | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 173 INTERYENTIONS RATIONALES before the first postpartum menses begin. Provide contraceptive counseling as indicated. Reassure nursing clients that pleasurable pelvic sen- sations associated with breasr-feeding are a normal result of uterine contrac- tion stimulated by the release of oxytocin. Refer ciient to caregives for unusual signs of pain on intercourse or sexual dys- Lnction. menstruation returns. Clienr may need informa- tion about contraceptive options. Reassurance validates the client's perceptions and allays guilt feelings that may be present when breast-feeding results in pleasurable sensations. Unusual pain or dysfunc- tion may be the result of physical or psychological complications. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did client and partner verbalize understanding of postpartum physiologic changes affecting sexudi- ty? Have client and partner identified ways to meet sexual needs during the puerperium?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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POSTPARTUM 175 Breast-Feeding Lactation is a normal physiologic process that pro- vides optimum nutrition for the infant. The hor- mones of pregnancy prepare the breasts for lacta- tion. The process is completed when the placenta separates and there is an abrupt drop in estrogen and progesterone. This allows the unobstructed influence of prolactin to stimulate milk produc- tion. Oxytocin is released by the posterior pitu- itary gland in response to suckling. This hormone causes contraction of the uterus (enhances involu- tion) and the myoepithelial cells in the breast alve- oli. Milk is then released into the ducts and sinus- es and ejected from the nipples. This is known as the “let-down reflex. ” The infant's cry or even just thinking about the infant may stimulate the reflex. If the mother is very tense and anxious, the let- down reflex may be inhibited causing frustration for both infant and mother. Colostrum is a clear yellow secretion produced by the breasts for the first four or five days after birth. It is gradually replaced by production of mature breast milk. Colostrum contains antibod- ies that may protect the infant from parhogens. In some cultures colostrum is thought to be unhealthy for the newborn and is discarded. On the 3rd or 4th day after birth the mother may notice breast discomfort associated with venous and lymphatic engorgement accompanying the start of lactation. This usually subsides within 24- 48 hours. Frequency of nursing has a direct effect on the level of prolactin released and therefore on the amount of milk produced. Most women will be discharged from the hospital before milk pro- duction begins. Anticipatory guidance and follow- up may be needed to ensure success. Contraindications Maternal cytomegalovirus, chronic hepatitis B, or HIV infection Maternal need for medications that may adversely affect the infant (the mother may pump her breasts for the duration of drug ther- apy and resume breast-feeding later) Advan tag es human milk is 95% esciently used by the human infant: breast-fed infants experience less constipation and gas than bottle-fed infants nursing accelerates uterine involution and loss children who were breast-fed have higher IQ of weight gained during pregnancy scores breast-fed infants have fewer allergies breast milk is free, warm, sterile, and always available Disadvantages the mother may feel “tied to the infant” in the early puerperium while supply is being estab- lished leaking breasts need to plan ahead to pump breasts when the mother will not be available for feedings Nursing Care Plans iritwl We fl-Being, Enhanced Potential gr (160) Related to: Life-affirming experience of success- fully breast-feeding a newborn infant. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
176 MATERNALINFANT NURSING CARE PLANS Additional Diagnoses and Plans Breast-Feeding, Effective Related to: Maternal-infant dyad satisfaction and success with breast-feeding process. Defining Characteristics: Client reports satisfac- tion with the breast-feeding process (specie: e. g., “I always breast-feed my babies, it's so easy”). Client positions infant to ensure good latch-on at the breast. Infant exhibits regular sucking and swallowing, appears content after feeding. Goal: Maternal-infant dyad continues to experi- ence effective breast-feeding by (datehime to eval- uate). Outcome Criteria Client reports continued satisfaction with breast- feeding. Client demonstrates skill with breast- feeding. Infant appears content after feeding. INTERVENTIONS RATIONALES Promote breast-feeding as soon as birth if client wish- es. Delay nonessential nursing care for 1-2 hours (e. g., weighing, footprints, eye prophylaxis, vitamin K injection, etc. ). Demonstrate respect for cultural variations in breast-feeding practices (e. g., some cultures discard the colostrum and feed the infant sugar water until the milk comes in). Encourage skin-to-skin contact for mother and infant. Place a warm blan- ket over mother and baby. Early breast-feeding takes advantage of the first peri- od of reactivity, promotes maternal homeostasis, and provides comfort for the infant after birth. Deeply held cultural beliefs are not likely to be changed by disapproval. Respect for variances pro- motes self-esteem and cul- tural integrity. Skin-to-skin contact pro- vides tactile stimulation, promotes attachment, and maintains the infant's tem- perature. INTERVENTIONS RATIONALES Assess client's previous experiences, knowledge, and skill (positioning, latch-on, removal, etc. ) with breast-feeding. Elicit questions or concerns. Share current research findings as appropriate. Ask client to share any tips she may have for others about breast-feeding (e. g., relieving engorgement, promoting “let-down” reflex, pumping, working, ecc. ). Facilitate client's breast- feeding by not offering supplements to the infant, promoting rooming-in, etc. as client desires. Praise client and infant for effective breast-feeding activity. Assessment provides infor- mation about knowledge and skills. Client may ben- efit from current research findings. Intervention promotes client's self-esteem and provides anecdotal infor- mation about successful breast-feeding techniques. Interventions promote infant's interest in nursing and allow frequent stimu- lation of the breasts. Praise reinforces effective breast-feeding. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client report continued satisfaction with breast-feeding? Does client demonstrate skill with breast-feeding? [Specify: e. g., positioning, latch- on, removal, etc. ] Does infant appear content after feeding?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 177 Nutrition, Altered Less Than Body Requirements Related to: Increased caloric and nutrient demands secondary to breast-feeding. Defining Characteristics: Client is breast-feeding her infant and reports, or is observed, eating less than the recommended daily allowance of calories and/or nutrients for effective lactation (specify for client). Goal: Client will ingest adequate calories and nutrients to promote effective lactation by (dadtime to evaluate). Outcome Criteria Client verbalizes the caloric and food guide pyra- mid requirements for good nutrition while breast- feeding her baby. Client plans to eat appropriate nutrients. INTERVENTIONS RATIONALES Assess client's weight, weight gain during preg- nancy, and ideal weight. Calculate caloric require- ments for lactation (usual- ly 500 kcal over regular dietary needs). Assess client's usual intake using 24-hour diet recall. Provide client with written and verbal information about daily nutrient and caloric needs during lacta- tion: PNV, 4 servings pro- tein, 5 servings dairy (I quart milk), 2-3 servings fruit (2 vitamin C-rich), 2- 3 servings vegetables ( 1 + green leafy), 2-3 quarts flu- ids. Assessment provides infor- mation about client's weight and individual caloric needs (2500 to 3000 calories for lacta- tion). Assessment provides infor- mation about current intake, Written instruction allows client to review material once she is discharged. For illiterate clients, materials may be in picture format. Individual instruction pro- motes compliance. INTERVENTIONS RATIONALES Assist client to compare usual diet with needs for lactation. Explore food preferences and cultural prescriptions. Assist client to plan daily food choices to meet lacta- tion needs while allowing for cultural/personal pref- erences and financial abili- ty. Provide time to prob- lem solve with client. Suggest that client have fluids accessible during breast-feeding sessions. Refer client for financial or nutritional assistance as needed (specify: e. g., social services, WIC, dietitian). Assistance empowers the client to evaluate her intake compared to needs for lactation. Client is most likely to adhere to a plan of her own devising. Pre-printed diets often are not cultur- ally sensitive, contain dis- liked foods (e. g., liver), and are too expensive. Breast-feeding stimulates thirst. This is a good time to include additional flu- ids. Referral helps clients with financial or unusual nutri- tional needs (e. g., diabetic or PKU mothers). Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Did client verbalize the caloric and food guide pyramid requirements for good nutrition while breast-feeding her baby? Did client plan to eat appropriate nutrients? Specify) (Revisions to care plan? D/C care plan? Continue care plan?) Breast-Feeding, Inefectiue Related to: Specify (e. g., maternal anxiety/insecu- rity/ambivalence, or discomfort, ineffective infant sucking/swallowing secondary to prematurity, cleft lip/palate, etc. ). | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
178 MATERNAL-INFANT NURSING CARE PLANS Defining Characteristics: Specify (e. g., infant not latched-on to breast correctly, nonsustained suck- ling, maternal perception of insufficient milk pro- duction, reports no “let-down” reflex, extremely sore nipples, etc. ). God: Client and infant will demonstrate effective breast-feeding by (date/time to evaluate). Outcome Criteria Client will identify actions to promote effective breast-feeding. Infant will latch-on correctly and nurse for 10 minutes. INTERVENTIONS RATIONALES Offer to assist client with breast-feeding. Assess client's beliefs, pre- vious experience, knowl- edge, and role models for breast-feeding. Provide for privacy and a calm, relaxed atmosphere. Reassure client that breast- feeding is a natural activity in which her body is pre- pared to engage. Teach client that relaxation is necessary for effective breast-feeding. Describe how the infant's behavior and the “let-down” reflex are affected by her emo- tions. Instruct client about com- fortable positions for breast-feeding. Suggest she keep a glass of water close Offering assistance obtains permission to assist client. Assessment provides infor- mation to help plan assis- tance. Lack of knowledge or support for breast-feed- ing may interfere with client's ability to succeed. Anxiety and embarrass- ment interfere with learn- ing. Reassurance helps client to believe in the wis- dom of her body. Teaching helps client understand that infants respond to their mother's emotional state and ten- sion level. Maternal ten- sion and emotional upset inhibit the “let-down” reflex causing frustration for the infant. Comfort promotes relax- ation. Nursing stimulates thirst and the client shouldn't interrupt feeding INTERVENTIONS RATIONALES by and use pillows for sup- port. Describe the feedback loop of milk production and suckling. Inform client that infant will need to nurse often (q 1 to 3 hr) at first in order to build up milk supply. The infant may need to nurse more frequently later during growth spurts at 2 and 6 weeks, then again at 3,4, and 6 months of age. Teach client that the infant will empty a breast within 10-15 minutes. The client may chose to alternate breasts once or more often during each feeding. The “hind milk” or last milk in the breast contains '? fat content to promote growth. Describe and demonstrate her infant's reflexes that facilitate breast-feeding (rooting, latching-on). Assist client to get herself and infant into a comfort- able position for nursing with infant's body flat against hers: “tummy-to- tummy. ” Teach client that the infant needs to have most of the areola in his mouth in order to empty the milk sinuses and avoid nipple soreness. to go get a drink. Pillows may help support client's arms to avoid discomfort or fatigue. Understanding the rela- tionship between milk supply and infant's suck- ling empowers the client to evaluate frequency of breast-feeding. Anticipatory guidance related to growth spurts helps the client feel secure about her milk supply. Understanding the physi- ology of breast-feeding promotes self-confidence and decision making about method for breast-feeding. Demonstration increases client's understanding of infant reflexes that pro- mote effective nursing. Client may benefit from suggestions about infant and self-positioning to avoid fatigue and promote correct latching-on. Teaching provides infor- mation about breast-feed- ing technique to avoid complications. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 179 INTERVENTIONS RATIONALES Encourage client to stimu- late infant's rooting reflex and help the infant to latch-on while his mouth is open. Show client how to hold her fingers in a “C” around the breast while nursing to ensure the infant's nose is not cov- ered. Teach the client how to break the suction by slip- ping a finger into the infant's mouth before removing him from the breast. Praise client for skill devel- opment and nurturing behaviors. Reinforce that breast-feeding is a natural process. Instruct client in breast care: wash hands before nursing; wash nipples with warm water and no soap, allow to air dry; may rub some colostrum or milk into nipples &er feeding. Describe what client will feel when her milk “comes in” (breast engorgement) and what she can do to ease discomfort: suggest warm showers, application of warm, moist cabbage leaves for 15 min, 9 fre- quency of breast-feeding or expression of milk, mild analgesics (acetaminophen) as ordered by caregiver. For nipple soreness, teach client to ensure the infant has the whole areola in his Encouragement and assis- tance help the client to develop needed skills for initiating nursing her infant. Demonstration facilitates maternal understanding. Newborns are obligate nose-breathers and will detach from the breast if unable to breathe. Teaching correct way to remove infant from the breast helps client avoid sore nipples. Praise increases self-worth and promotes confidence in abilities. Instruction promotes self- care. Handwashing pre- vents the spread of pathogens; soap may dry the nipples causing cracks; colostrum and milk have healing properties. Anticipatory guidance and suggestions decrease anxi- ety and promotes effective self-care. Moist heat causes vasodilatation and decreas- es venous and lymphatic congestion; cabbage leaves are anecdotally reported to be effective, emptying the breasts 4 feelings of full- ness. Interventions promote nipple integrity and heal- ing; the hungry infant may INTER~N'I'IONS RATIONALES mouth; begin with non- tender side first; apply warm, moist compresses (breast pads or tea bags) to nipples after feeding, Rub milk into nipples and allow them to air-dry. Avoid using nipple shields. Teach client that infants are usually alert in the first hour after birth and again at 12 to 18 hours, but oth- erwise are often very sleepy. The baby wifl wake up when he is hungry. Reassure client that the baby is getting enough milk if he gains weight, wets 6 or more diapers per day, and appears content for an hour or more after eating. Encourage client to explore her feelings about breast-feeding. Discuss client concerns about modesty, working, etc. Praise client's attempts and successes. Reinforce the benefits of breast-feeding if only for the first few weeks or months. Refer client as indicated (specifjr: e. g., to a lactation specialist, other mothers breast-feeding multiple infants, books on breast- feeding, or La Leche League, etc. ). suck more vigorously on the first side; moist heat promotes dilation and healing; milk has heating properties. Nipple shields have been shown to J, the amount of milk the infant can obtain. Teaching the mother to respond to her infant's hunger cues promotes self- confidence and success. New mothers often feel that they have faiied if their infant is sleepy and doesn't nurse well in the hospital. Mothers are sometimes concerned when they can't measure how much milk the infant has received. Six wet diapers indicate ade- quate fluid intake. Client may have concerns that increase anxiety and interfere with successful breast-feeding. Praise helps bolster self- confidence and intent to continue breast-feeding. Referral provides addition- al information and assis- tance. A lactation specialist may be needed for concin- ued difficulty or special needs. La Leche League provides information and support for breast-feeding mothers. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
180 MATERNAL-INFANT NURSING CARE PLANS Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did client identifjl actions to promote effective breast-feeding? Speci9. Did infant latch-on cor- rectly and nurse for 10 minutes?) (Revisions to care plan? DIC care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPMTUM 181 Breast-Feeding birth and placental separation t prolactin release milk production I 4 infant suckling . t t involution 1 infant satiety 1 4-sucking 1 L mi& production | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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POSTPARTUM 183 Puerperal hemorrhage is classified as early (within the first 24 hours) or late (after the first 24 hours and up to 6 weeks postpartum). The causes of early hemorrhage are uterine relaxation (atony), lacerations, uterine rupture, hematomas, retained placental fragments, and coagulation deficiencies (DIC). Late puerperal hemorrhage may be related to abnormal healing of the placental site or retained placental fragments. The amount of blood lost during a hemorrhage greatly exceeds the usual definition of more than 500 cc. Risk Factors poor general health status: malnutrition, infec- over-distended uterus during pregnancy: macro- somic infant, hydramnios, multiple gestation, uterine fibroids tion, anemia, PIH, clotting deficiencies grand multiparity rapid or prolonged labor, oxytocin induction or augmentation medications: Mg S04, deep general anesthesia placental defects: history of previa, abruption, (halo thane) incomplete separation, placenta acreta difficult birth: forceps rotation, intrauterine manipulation Medical Care Evaluation of the placenta and membranes for completeness followed by intrauterine examina- tion and manual removal of any missing pieces Fundal massage or bimanual compression of the uterus Uterotonic medications: oxytocin, methyler- gonovine maleate (Methergine), Ergotrate, or prostaglandins Evaluation of the cervix and vagina for lacera- tions if the fundus is firm and bleeding contin- ues IV fluid replacement, initiation of a second IV, and blood transfusion as needed Foley catheter to evaluate renal function, oxy- Surgical exploration and repair as indicated: lac- eration repair, hematoma evacuation and liga- tion of bleeders, possible ligation of uterine arteries or hysterectomy gen therapy Nurs Cng Care Plans Fluid Volume Deficit, Risk for (159) Related to: Excessive losses secondary to compli- cation of birth (specify: e. g., atony, lacerations, etc. ). Infiction, Risk for (1 65) Related to: Compromised defenses secondary to decreased circulation, puerperal site for organism invasion. ion, Altered (cerebral, renal, peripheru Tissue "j; ) Related to: Excessive blood loss secondary to (specify: e. g., uterine atony, retained placental fragments, lacerations of the birth canal, retroperi- toned hematoma, etc. ). Defining Characteristics: Specify (e. g., EBL, B/1?, P, R, Sa O2, skin color and temperature, urine output, LOC, etc. ). | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
184 MATERNAL-INFANT NURSING CARE PLANS Goal: Client will maintain adequate tissue perfu-INTERVENTIONS RATIONALES sion by (date/time to evaluate). gor, and capillary refill tissue perfusion. Outcome Criteria Client will maintain B/P and pulse (speci Q for-.. (specify frequency). Hypovolemia results in shunting of blood away from the peripheral circu--. client: e. g., > 100/60, pulse between 60-90), skin warm, pink, and dry; urine output > 30 cc/hr; lation to the brain and vital organs. client will remain alert and oriented). Specify action of drugs. INTERVENTIONS RATIONALES Assess client's B/P, P, R, and Sa02, (specify fre- quency). Assess fundus, perineum, and bleeding. Evaluate blood loss by weighing peri pads or chux (1 gm = 1 cc). (Specify frequency of documentation. ) Notify caregiver of I' losses. Insert foley catheter as ordered. Monitor hourly intake and output. Monitor for restlessness, anxiety, c/o thirst, “air hunger,” and changes in level of consciousness. Administer humidified oxygen at 8-12 L/min via facemask as ordered. Assess client for abdominal pain, rigidity, increasing abdominal girth, vulvar or vulvovaginal hematomas. Assess client's skin color, temperature, moisture, tur-Assessment provides infor- mation about hypo- volemia. Excessive losses cause 4 BIP with9 P and 9 R as compensatory mechanisms. Assessment provides infor- mation about uterine tone and position, hematoma development, extent of losses. Interventions provide information about renal perfusion and function. Intake and output evalu- ates fluid balance. Intervention provides indi- cations of inadequate cere- bral tissue perhsion. Intervention provides sup- plemental oxygen for tis- sues. Assessment provides infor- mation about possible uterine rupture or internal hematoma formation and hidden bleeding. Assessment provides infor- mation about peripheral Administer medications as ordered (specify: e. g., oxy- tocin, ergotrates, prostaglandins). Initiate secondary IV access with 18 gauge (or larger) catheter and pro- vide fluids, blood prod- ucts, or blood as ordered (specify fluids and rate). Monitor laboratory values as obtained (e. g., Hgb, Hct, clotting studies). Observe client for signs of spontaneous bleeding (e. g., bruising, epistaxis, seeping from puncture sites hema- turia etc. ). Keep client and significant other informed of client's condition and current plan of care. Notify caregiver of all find- ings and prepare for imme- diate surgical intervention if ordered. Intervention provides venous access to give med- ications or replace fluids. Size 18 gauge or larger is preferred to transfuse blood. Laboratory values may provide information about extent of losses or impend- ing DIC. Observation provides information about the depletion of clotting fac- tors and development of DIC. Information promotes understanding and cooper- ation. Surgical intervention may be required if other mea- sures are ineffective in stopping hemorrhage. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What are client's B/P and P? Is skin warm, pink, and dry? Is urine output > 30 cc/hr? Is client alert and oriented?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 185 (Revisions to care plan? D/C care plan? Continue care plan?) Fear Related to: Perceived grave danger to self or infant secondary to (specify: e. g., postpartum hemorrhage, infant with a congenital anomaly, etc. ). Defining Characteristics: Client or significant other state (specify: e. g., “I'm scared; What's wrong with my baby?” etc. ). Client and signifi- cant other demonstrate physical signs of fear (specify: e. g., sympathetic response: pale, f P, f R, dry mouth, nausea, etc. ). Goal: Client and significant other will cope with fear while emergency interventions are being employed. Outcome Criteria Client and significant other can identify the threat. Client is able to cooperate with instruc- tions from caregivers. INTERVENTIONS RATIONALES Inform client and signifi- cant other of a problem as soon as it's identified. Speak slowly and calmly. Calm information 4 fears. It is more frightening to “sense” that something is wrong than to know what it is. Simple explanations are less frightening than com- plicated physiology or medical terminology the client may not understand. Describe the problem in simple terms and what interventions might be expected (specify: e. g., for hemorrhage the nurse will start another W, massage the hndus; the neonatolo- gist is resuscitating the baby, etc. ). Explain all equipment and procedures as they're being done (specify: e. g., foley catheter, W, ambu bag and mask, etc. ). Explanation promotes understanding of unfamil- iar interventions. INTERVENTIONS RATIONALES Inform client and signifi- cant other of things they can do to help (specify: e. g., position changes; keep on oxygen mask; sig- nificant other can support client, etc. ). Observe client and signifi- cant other for signs of dis- tress: pallor, trembling, crying, etc. Provide emo- tional support. Encourage significant other to remain with client. Allow expression of feel- ings (helplessness, anger). Support cultural variation in emotional expression. Inform client and signifi- cant other when crisis has passed. Provide informa- tion about what will hap- pen next. Praise client and signifi- cant other for their coop- eration and coping during a stresshl event. Visit client after birth (specify when: e. g., 1st or 2nd PP day) to discuss events surrounding birth. Clarify any misconceptions about the emergency or complication. Information promotes a sense of control over frightening events to be able to be involved in the solution. The “fight or flight” sym- pathetic response may indicate f fear. Emotional support helps the client and significant other to cope. Significant other provides support during a stressful period. Allows understand- ing of events. Intervention shows respect for client's experience and cultural expression of emo- tion. Information allows client and significant other to reevaluate their feelings and consider what to expect next. Praise enhances self- esteem. Intervention shows that the client's abilities are valued. Visiting the client after the crisis has passed provides an opportunity to relive the experience and fill in any gaps in understanding before discharge. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
186 MATERNALINFANT NURSING CARE PLANS Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did client and significant other verbalize correct understanding of the emergency? Was client able to cooperate with instructions? Specify) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPm TUM 187 Postpartum Hemorrhage Risk Factors Birth Trauma retained placental vaginal + or membrane cervical coagulation defects + uterine atony 1 lacerations large hematomas ineffective fundus firm bleeding from uterine continued all sites bleeding/ shock 1 I fra Tts bleeding from placental site-contraction correction of repair of underlying lacerations cause uterine exploration removal of ligation of fragments arteries fluid replacement transfusion blood and blood products I drugs bimanual compression | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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POSTPARTUM 189 Episiotomy and lacerations Episiotomy is an intentional incision into the per- ineum designed to facilitate birth and avoid per- ineal lacerations. Midline episiotomy is the most common procedure in the United Stares. Mediolateral episiotomy is an incision from the midline of the posterior vagina and extends at a 45" angle to either left or right. ~ediolateral epi- siotomies provide more room without danger of extension into the rectum. They bleed more and cause greater discomfort postpartum than midiine episiotomies. Lacerations of the perineum or vagina may occur during birth. This is more common in nulliparas and young clients, when an episiotomy has been done (extension), or the client has a vacume extractor or forceps-assisted birth, 1st degree: laceration through the skin and mucous membrane only Application of ice packs for the first 8 hours folluwed by sitz baths (warm or cool) 3 or 4 times per day Nursing Care Plans Pain ~~~~ Related to: Tissue muma secondary to (specify: e. g., operative obstetrics, vaginal birth). Defining Characterisiks: Client reports pain (specifj, toation and severity based on a scale of I to 10). Client exhibits grimacing, crying, reluc- tance to move affected area, etc. (specify). Infiction, ~isk~~ (165' Related to: Site for organism invasion secondary to (specify: e. g., episiotomy, lacerations, etc. ). Additional Dia~n~ses a~d Plans ~~~~~~ i in^^^^ ~~~~~~ Ahmd Related to: Diminished bladder tone and sensa- tion secondary to (spec+: e. g., childbirth trauma; anesthesia; periurethral edema). 2nd degree: continues into the under Iyin~ fascia and muscfes of the perineaf body 3rd degree: continues through to the anal sphincter 4th degree: extends through the rectal mucosa Defining ~~~~t~~isti~: Client exhibits biadder distention and inability to complerely empty bladder when voiding fspecifj for cfienr). Goal: Client wilt regain normal urinary efimina- tion patterns by (dateftime tu evafuate). Outcome Criteria Client demonstrates ability to empty bladder completely every 2 to 4 hours. Client verbalizes signs and sy~pto~~ of urinary tract infecti~n to report. Medical Care Surgical repair under local or regional anesthesia Mild analgesics, anesthetic sprays or cream, stool softeners; clients with epidurals may receive intrathecal narcotics for 4th degree lac~rations/ext~nsions | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |