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NURSING DIAGNOSIS (NURSING DIAGNOSIS # 1 : Risk for infection, related to…
NURSING DIAGNOSIS
NURSING DIAGNOSIS # 1 : Risk for infection, related to repeated invasive procedures: GOAL: Patient will be free of signs of infection during shift.
NURSING INTERVENTIONS:
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Monitor temperature, pulse, and WBC count as indicated((Increased temperature or pulse greater than 100 bpm may indicate infection. Normal protective leukocytosis with WBC count as high as 25,000/mm 3 must be differentiated from elevated WBC count caused by infection).
Perform perineal care per protocol, using medical asepsis. (Helps promote cleanliness;prevents development of an ascending). uterine infection and possible sepsis).
Perform vaginal examination only when absolutely necessary, using aseptic technique. (Repeated vaginal examinations increases the risk of endometrial infections).
Note date and time of rupture membranes. (Whitin 4 hr after rupture of membranes, the client and fetus are at increased risk for ascending tract infections and possible sepsis).
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NURSING DIAGNOSIS # 2: Impaired tissue integrity related to passage of fetus through birth canal.
GOAL: Client will relax perineal musculature during bearing down efforts.
NURSING INTERVENTIONS:
Help client as needed in assuming position of choice. Monitor safety, and support legs, especially if epidural (or caudal) catheter is in place. (Reduces risk of injury, especially if client is unable to assist with transfer).
Assist client with proper positioning, breathing, and efforts to relax. Ensure that client relaxes the perineal floor while using abdominal muscles in pushing. ( Helps promote gradual stretching of perineal and vaginal tissue.)
Place client in left lateral Sim's position for delivery, if desired/comfortable. ( Reduces perineal tension, promotes gradual stretching, and reduces need for episiotomy),
Offer use of birthing bed in upright position. Encourage Fowler's position, or standing while pushing, it these positions are not contraindicated.
Lift legs simultaneously, if leg supports/stirrups are used, and place feet and legs properly in low position, supporting feet.
EVALUATION: Patient had vaginal tear during delivery, sutured by Doctor.
NURSING DIAGNOSIS # 3: Risk for fluid volume deficit, related to mouth breathing.
GOAL: Client will maintain fluid intake as able.
NURSING INTERVENTIONS:
Assess production of mucus, amount of tearing within eyes, and skin turgor. (Provide information on the hydration status of the client)
Monitor intake and output. Note urine specific gravity. Encourage client to empty bladder at least once every 1 1/2-2 hrs. (I & O should be approximately equal, dependent on degree of hydration. Concentration of urine increases as urine output decreases and may warn of dehydration. Fetal descent may be impaired if bladder is distended.
Determine cultural practices regarding intake. ( cultures like Mexican women practice of drinking milk to make their babies larger, and drinking chamomile tea to have a healthy labor)
Monitor V/S FHR as indicated ( Increases in temperature, BP, pulse, respirations and FHR may indicate presence of dehydration.
Administer bolus of parenteral fluids, as indicated. ( May be needed if oral intake is inadequate or restricted. In the event of dehydration or hemorrhage, fluid resuscitation is necessary; counteracts some negative effects of anesthesia/analgesia.)
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