Care plan brenda patton PDF

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HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

NURSING HISTORY Client’s Initials: B.P____ Informant: _Client____________________

Relationship to informant: ____Self______

Age: __18_______ Gender: ____F_____ Admitting Diagnosis: _Ruptured membranes ____ Chief Compliant: _____ G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor assessment. The patient states that her water may have broken earlier this morning and she thinks she is in labor. Amnisure was positive History of Present Illness: _No medical history Allergies: __No known allergies Medications: ______ Penicillin 5 million units IVPB (now), Penicillin 2.5 million units IVPB every 4 hours until delivery, Promethazine 12.5mg IVPB every 4 hours PRN for nausea/vomiting, Lactated Ringers’ 500ml IV bolus for nonreassuring fetal heart rate pattern Past Medical History: N/A________________________________________________________________________________ _ Immunizations: __N/A____________________________________________________________________________________

Psychosocial History: N/A

Family History: _N/A________________________________________________________________________________________

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HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

Name: _Alexa Mascia______ __ Pt's Initials: B.P____ Age _18___ Gender: ___F___ _ Diagnosis _ROM Labor_____ _ Date:11/28__

Assessment

Subjective data: Pt states “I have pain everywhere” Pt states, “I think my water broke this morning” Pt states she is nauseous Objective data: FHR 145 with occasional accelerations. EFM was placed on the patients RLQ of abdomen. Positive vaginorectal Group B Streptococcus screening culture. WBC 11*10^9/L. Cervix is effaced

Nursing Diagnosis Risk for infection r/t rupture of amniotic membrane as evidence by positive amnisure test

Pathophysiology

Goals

“Group B Streptococcus (GBS), also known as group B strep, Streptococcus agalactiae, Strep B, or Beta Strep, is a type of bacteria that is naturally found in the digestive and lower reproductive tracts of both men and women.” babies can be infected by GBS before birth and up to about 6 months of age due to their underdeveloped immune systems. GBS most commonly causes sepsis, meningitis, and pneumonia. Some GBS survivors experience handicaps such as blindness, deafness,

Short term goal: Client will remain free of signs and symptoms of infection (afebrile, amniotic fluid will be nearly colorless and odorless. Long term goal Baby will be born without acquiring strep b infection

Outcomes/Plannin g Nursing staff will remail using aseptic care during vaginal assessments Client will be educated on the potential risks if her baby gets strep b infection

Nursing Interventions 1. Administer antibiotics as ordered

2. Monitor VS and wbc count regularly

Rationale

Evaluation

Helps prevent the growth of bacteria from reaching the vagina

Short term goal reached client remained free of symptoms of infection

The incidence of chorioamnioniti s increases within 4 hours of ruptured membranes as evidence by elevation of WBC and abnormal vital signs

Long term goal reached clients baby was born without aquiring strep b infection

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HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

at 50% and 4cm open. Vertex fetal presentation at -2 station. Postive amnisure test VS: HR 90 bpm, BP:120/72mmHg, R:20, T: 37 C, O2: 97%.

and mental challenges, and/or cerebral palsy. Only a few babies who are exposed to GBS become infected, bit GBS can cause babies to be miscarried, stillborn, or become very ill and sometimes die after birth (CDC, 2020)

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HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

Assessment

Nursing Diagnosis Subjective data: Pt Risk for fetal thinks her water injury r/t broke this morning infection as evidence by Objective data: positive strep b Heart rate: 91. culture Pulse: Present. Blood pressure: 120/71 mmHg. Respiration: 20. SpO2: 97%. Temp: 37 C.. Fetal heart rate: 141 .. Clear fluid visible on the bed sheets, Positive for group b Strep

Pathophysiolog y

Goals

Outcomes/Plannin g Short-term Nurses will goal: x 24 continuously hours Fetus monitor fetal heart will display and assess if a FHR and beat- cesarean delivery to beat is necessary variability within normal Client will be limits, with no educated on the ominous risk factors of periodic neonate infection changes in and when to seek response to medical attention uterine contractions Long-term goal: x 7 days Baby will be born free of injury

Nursing Interventions 1. Monitor baseline FHR manually and/ or electronically. Evaluate frequently per protocol. Note FHR variability or periodic changes in response to uterine contractions 2. Perform Leopold’s maneuvers to determine fetal engagement, position and presentation. 3.Administer oxygen via nonrebreather face mask

Rationale

Evaluation

Normal range for fetal heart rate is between 120-160 bpm with average variability, accelerating in response to maternal activity fetal movement and uterine contractions

Short term goal met, fetus heartbeat remained variable and within range.

Long term gal met baby was born free of injury

A transverse lie or breech presentation may necessitate a cesarean birth. Increase maternal oxygen available for fetal uptake

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HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

References: National Center for Immunization and Respiratory Diseases, Division of Bacterial Diseases. (May 21, 2019) Group B Strep (GBS). Martin, P. BSN, RN. Nurseslabs. (2019) 36 Labor Stages, Induced and Augmented Labor Nursing Care Plans. Retrieved from Pillitteri, J.S. A. (2010). Lippincott CoursePoint Enhanced for Silbert-Flagg and Pillitteri's Maternal and Child Health Nursing.

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