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18-year-old Caucasian Female. 5’2”, 179 lbs,32.74kg/m^2 BMI. Admitted for…

- - - - OUTCOME:
        
        Client will develop/maintain a good labor pattern; i.e., contractions 2–3 min apart, lasting 40–50 sec, with uterine relaxation to normal tone between contractions
        
        Client will accomplish delivery without complications.
      - INTERVENTION Review prenatal record for history of previous pregnancies and outcomes, prenatal laboratory studies, pelvic measurements, allergies, weight gain, vital signs, last menstrual period, and EDB. RATIONALE: Provides information needed in formulating plan of care. Alerts nurse to the possibility of existing or developing problem(s).
      - INTERVENTION Observe safety precautions related to the use of infusion and to proper labeling of oxytocin solution RATIONALE Errors or fluctuations in rate of administration may cause under medication or over medication, resulting in inadequate contractions or uterine rupture. Drug delivery is verified by closely monitoring the pump and the decreasing level of fluid.
      - INTERVENTION Obtain/monitor electrolytes, as indicated. RATIONALE Water retention may occur during oxytocin infusion resulting in hypochloremia or hyponatremia.
      - INTERVENTION Dilute and administer oxytocin (Pitocin) in electrolyte solution with a two-bottle IV system, piggy-backing oxytocin close to IV site, according to unit policy and procedures. RATIONALE: The synthetic hormone oxytocin stimulates the uterine smooth muscle, increasing the excitability of the muscle cells, which increases the strength of contractions. Oxytocin can be discontinued if
        necessary, and the primary site can be quickly cleared and available for other infusions when solution is infused close to IV site. In addition, water intoxication can result from excessive or rapid fluid
        administration, especially when D5W is used instead of electrolyte solutions (e.g., lactated Ringer’s)
- - - - AEB
        
        Changes in pulse rate and variations in blood pressure
        
        Outcomes
        
        Patient will maintain blood pressures appropriate for stage of labor.
        
        Patient will use appropriate techniques to sustain/enhance vascular return.
        
        INTERVENTION: Monitor BP and pulse immediately after administration of anesthesia, and repeat until client is stable RATIONALE: Hypotension is the most common adverse reaction to lumbar epidural or subarachnoid (low spinal) block as vascular dilation slows venous return and reduces cardiac output.
        
        INTERVENTION: Encourage client to inhale/exhale during bearing-down efforts, using an open glottis technique and holding breath no longer than 5 sec at a time. Instruct client to push only when she feels the urge to do so. Avoid forced pushing. RATIONALE: Repeated, prolonged Valsalva’s maneuvers (occurring when the client holds her breath while pushing against a closed glottis) eventually interrupt venous return and reduce cardiac output, BP, and pulse pressure. Avoiding Valsalva’s maneuver minimizes fall of maternal PO2 and rise in PCO2 levels, which would have a negative impact on fetus.
        
        INTERVENTION: Regulate IV infusion as indicated; monitor oxytocin administration, and decrease rate if necessary. RATIONALE: IV line (or saline lock access) should be available in case the need to correct hypotension or administer emergency drugs arises. Excess fluid retention (a possible adverse reaction of oxytocin) may
        contribute to development of intrapartal toxemia.
        
        INTERVENTION: Monitor blood pressure and pulse rate frequently. Every 3-15 minutes. Note amount and concentration of urine output. Test for albuminuria. RATIONALE: Increases in cardiac output of 30%–50% occur in the expulsion stage, peaking at the acme of uterine contractions and slowly returning to a pre-contractile state as the contraction diminishes or ceases. Intrapartal toxemia due to stress, excess sodium and fluid retention, or oxytocin administration may be manifested by increased BP, decreased urine output, and increased concentration of urine.
- - - - AEB
        
        Facial mask of pain. Distraction behaviors such as restlessness, moaning, crying.
        
        OUTCOMES
        
        Patient will participate in behaviors to diminish pain sensations and enhance comfort.
        
        Patient will appear relaxed between contractions.
        
        INTERVENTION: Review/provide instruction in simple brreathing techniques. RATIONALE: Encourages relaxation and gives client a means of coping with, and controlling the level of, discomfort.
        
        INTERVENTION: Provide comfort measures (e.g., effleurage, back rub, propping with pillows, applying cool washcloths, offering ice chips/lip balm) RATIONALE: Promotes relaxation, reduces tension and anxiety and enhances client’s coping and sense of control.
        
        3.INTERVENTION: Establish a rapport that enables client/ partner to feel comfortable asking questions. RATIONALE: Answers to questions can alleviate fear and promote understanding.
        
        INTERVENTION: Encourage and assist client with change of position, and readjust EFM. RATIONALE: Prevents/limits muscle fatigue; enhances circulation.
- - - - Outcomes
        
        Patient will remain infection free of any signs of infection.
        
        Patient will demonstrate techniques to minimize risk of infection.
      - INTERVENTION: Monitor vital signs, and white blood cell (WBC) count, as indicated. RATIONALE: The incidence of chorioamnionitis (intra-amniotic infection) increases within 4 hours after rupture of membranes, as evidenced by elevations of WBC count and abnormal vital signs.
      - INTERVENTION: Demonstrate good hand washing techniques.RATIONALE: Reduces risk of acquiring/spreading infective agents.
      - INTERVENTION: Perform initial vaginal examination; repeat only during contractile pattern or client’s behavior indicates significant progress of labor. RATIONALE: Frequent vaginal examinations can lead to the incidence of ascending tract infections.
      - INTERVENTION: Use aseptic technique during a vaginal examination. RATIONALE: examination. Helps prevent the growth of bacteria; limits contaminants from reaching the vagina.