CUES (defining characteristics of Nrsg Dx) Subjective: “Masakit yung tahi ko lalo na kapag gumagalaw ako†Objective: >Facial Grimace with pain scale of 4 >Protective Gesture to avoid pai…Full description
nursing care planFull description
Full description
Full description
Community Health NursingFull description
Full description
Full description
Full description
Perioperative Nursing Care PlansFull description
Full description
Full description
CARE OF CLIENTS ACROSS THE LIFESPAN WITH PROBLEMS ININFLAMMATORY AND IMMUNOLOGIC REACTIONS, CELLULARABERRATIONS, ACUTE BIOLOGIC CRISIS, INCLUDING EMERGENCYAND DISASTER NURSING
Full description
ncpFull description
Full description
NURSING MANAGEMENT OF THE CHILDBEARING FAMILY
1
INTRAPARTUM
Nursing Care During Labor and Birth . 1. Differentiate between true and false labor
True
Contractions Frequency regular Intensity increasing Duration increasing Activity increases intensity Pain location lower back Radiating to lower abd.
Cervix Dilation progressive Effacement progressive Position anterior
Baby Engagement yes Comfort measures
no effect
Care begins with the onset of labor or when the one of the following is reported. Onset of progressive, regular uterine contractions that increase in frequency, strength, and duration Blood-tinged mucoid vaginal discharge indicating that mucous plug (operculum) has passed (could be a prodromal sign if not accompanied by onset of regualar contractions.) Fluid discharge from vagina (ROM may not be accompanied by onset of regular contractions, but care will begin when membranes are ruptured.)
NURSING MANAGEMENT OF THE CHILDBEARING FAMILY
2
INTRAPARTUM
2. Describe important information that is available on the prenatal record. Age Height & weight (update) Medical conditions OB hx and complications EDB Maternal wt. gain Labs: blood type and Rh, CBC, rubella, serology (VDRL), HBsAG, Group B Strep, UA, HIV, drug screening • • • • • • •
3. Discuss information to be collected during the admission interview. •
•
Confirm EDB Chief complaint onset of contractions frequency duration intensity changes •
• • • •
•
bloody show description •
•
ROM
What time did this happen Description of Fluid •
• • •
Last meal Birth Plan Infant feeding method
NURSING MANAGEMENT OF THE CHILDBEARING FAMILY
3
INTRAPARTUM • • • • •
Pediatrician Psychosocial factors Abuse Address concerns about labor Cultural Factors
5. Describe the general care of the family during each stage of labor.
First Stage of Labor Assessment and nursing diagnosis Determination of true or false labor Contractions Cervix Fetus Physical examination General systems assessment Vital signs Leopold’s maneuvers Assessment of FHR and pattern Admission to labor unit Admission data Prenatal record Interview Psychosocial factors Women with a history of sexual abuse Stress in labor Cultural factors Assessment of uterine contractions
Determine effectiveness. Are they powerful enough to expel the contents of the uterus? Frequency Intensity Duration
NURSING MANAGEMENT OF THE CHILDBEARING FAMILY
4
INTRAPARTUM
Resting tone Report to provider Vaginal examination Cervical effacement, dilation, fetal descent Determines true labor Status of membranes Dilation and effacement Presenting part Position Station Perform a Vaginal Exam When: • • • • • •
There is significant change in UA Urge to push Membranes Rupture Variable Decelerations Admission Medication
It is a sterile procedure!!!!!!!!!!!! Laboratory and diagnostic tests • •
Analysis of urine specimen Blood tests
Assessment of amniotic membranes and fluid • •
•
SROM or AROM will induce labor Assess color, viscosity/odor, amount, S&S of infection (Table 18-3 page 510) Document on labor record and report Abnormal findings.
Always assess FHR when membranes rupture ASAP!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! •
Signs of potential problems (Box 18-6)
NURSING MANAGEMENT OF THE CHILDBEARING FAMILY
5
INTRAPARTUM
Plan of care and interventions
Standards of care are the same that we use for any patient
Physical nursing care during labor (Table 18-4 page 513) • General hygiene • Nutrient and fluid intake Elimination-Carefully monitor I&0 especially • with epidural. • Ambulation and positioning
Supportive care during labor (Table 18-5) • Nurse • Father or partner • Grandparents • Doulas • Siblings during labor and birth
Emergency interventions (Page 523)
Second Stage of Labor Infant is born Begins with full cervical dilation (10 cm) Complete effacement Ends with baby’s birth
Table 18-6 Preparing for birth Maternal position Bearing-down efforts • Valsalva maneuver
Fetal heart rate (FHR) and pattern
Location of the FHR will change at this point in labor due to internal rotation. For example a baby at ROA will
NURSING MANAGEMENT OF THE CHILDBEARING FAMILY INTRAPARTUM
turn OA for birth. PMI will move down and toward center. Support of father or partner Supplies, instruments, and equipment Birth in a delivery room or birthing room Birth in LDR or LDRP room Mechanism of birth: vertex presentation Prevention of meconium aspiration Use of fundal pressure Immediate assessment and care of newborn Perineal trauma related to childbirth Lacerations Perineal lacerations Vaginal and urethral lacerations Cervical injuries Episiotomy
Emergency childbirth (Box 18-9)
Third Stage of Labor Placental separation and expulsion Firmly contracting fundus Change in uterus Sudden gush of dark blood from introitus Apparent lengthening of umbilical cord Vaginal fullness Collaborative care Placental examination and disposal Cultural preferences Maternal physical status Physiologic changes to prepregnancy status Signs of potential problems Excessive blood loss Alteration in vital signs and consciousness Care after placental delivery Care of family during the third stage Family-newborn relationships
6
NURSING MANAGEMENT OF THE CHILDBEARING FAMILY INTRAPARTUM