Please enable JavaScript.
Coggle requires JavaScript to display documents.
31 y/o F admitted for labor - Coggle Diagram
31 y/o F admitted for labor
labs/tests
platelet count 99 on admission, trending down to 90 6 hrs later
past history of thrombocytopenia
meds
Pitocin, increased to 20 units gradually to induce contractions
lactated ringers 500ml PRN to prevent hypovolemia
ketorolac prn every 4 hrs for pain
nursing diagnosis : acute pain r/t pressure on adjacent structure AEB verbalizations
long term goal evaluation: pt is able to demonstrate breathing techniques and positioning to reduce pain
short term goal: pt will report discomfort is minimized
long term goal: pt will continue to use techniques to control pain
short term goal evaluation: pt verbalized a reduction in pain
interventions with rationale:
assess degree of discomfort through verbal and non verbal cues. Attitudes and reactions to pain are individual and based on past experiences
provide info about available analgesics, side effects and responses. allows client to make informed choice about means of pain control
monitor FHR electronically and note decreased variability or bradycardia. Decreased FHR variability is a common side effect of many anesthetics/analgesics
assist with comfort measures. promotes relaxation and hygiene, enhances feeling of well-being
nursing diagnosis: fatigue r/t changes in energy production AEB lethargy
short term evaluation: pt is able to conserve energy
short term goal: client will use techniques to conserve energy between contractions
long term evaluation: pt seems to be more aware of what is happening with her energy levels
long term goal: client will report sense of control
interventions with rationale
Assess degree of fatigue. Fatigue may interfere with the clinets physical and psychological abilities to maximally participate in labor process
Monitor energy level of partner. Allows partner to have a brief break and refresh self enhancing ability to maintain focus and support client
Plan care to limit interruptions. Maximizes opportunities for rest.
provide dimly lit, nondistracting environment. Reducing stressors helps promote rest.
nursing diagnosis: Deficient knowledge R/T information misinterpretation AEB questions
long term goal: client will participate in decision-making process
long term evaluation: client is able and willing to participate in the plan of care for the labor and delivery process
short term evaluation: pt understands what is going to happen during the labor and delivery process
short term goal: client will verbalize understanding of psychological and physiological changes
interventions with rationale
Provide and discuss options for care during the labor process, provide information about birthing alternatives. Active participation of the client/couple is important in the decision-making process
Provide information about procedures and normal progression of labor. Prenatal education can facilitate the labor and delivery process, assist the client in maintaining control during labor and help promote a positive attitude.
Assess client's baseline knowledge and expectations during pregnancy. This will guide in establishing learning needs and set priorities
Review appropriate activity levels and safety precautions, whether client remains in hospital or returns home. Provides guidelines for client to make appropriate informed choices, allows client to engage in safe diversional activities to refocus attention.
nursing diagnosis: Risk for fluid volume deficit R/T vomiting.
long term goal: client will demonstrate adequate contraction of the uterus with blood loss within normal limits
long term evaluation: pt is demonstrating normal signs of labor
short term evaluation: pt is displaying recent BP and heart rate WNL
interventions and rationale
instruct the client to push with contractions; help direct her attention toward bearing down. Bearing down helps promote separation and expulsion, reduces blood loss and enhances uterine contraction
Palpate uterus; note "ballooning". Suggests uterine relazation with bleeding into uterine cavity.
Monitor for signs and symptoms of excess fluid loss or shock. hemorrhage associated with fluid loss greater then 500 ml may e manifested by increased pulse, decreased BP
Massage uterus gently after placental expulsion. Myometrium contracts in response to gently tactile stimulation, thereby reducing lochial flow and expressing blood clots.
short term goal: client will display BP and heart rate WNL