SY 2019-2020
COLLEGE OF NURSING
Silliman University
Dumaguete City
NURSING CARE PLAN ON
RUPTURE OF MEMBRAMES ON FULL TERM PRIMIGRAVIDA
Submitted to:
Assistant Professor Barbara Lyn A. Galvez
Prepared by:
Julia Banagodos
Diosdado O. Cajes III
Zarah Thea C. Estoquia
Ann Jeannith C. Malayo
CUES/EVIDENCES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Objective data: ● Anxiety r/t After 1 hour of 1. Provide 1. These After 1 hour of
● Poor eye contact fear for the rendering nursing reassurance measures rendering nursing
● Increased wariness well being of care, the client will and support; communicate care, the client has
● Fidgeting mother and be relieved from acknowledge care and been relieved from
● Maternal vital fetus anxiety as anxiety and use concern for the her anxiety as
secondary to evidenced by: touch, speak woman. They evidenced by :
signs:
situational slowly, and also prevent
BP:110/90 crisis as 1. Appear relaxed remain calm. transmission of 1. Patient looks
Maternal evidenced by and report relaxed and
anxiety from the
Pulse rate: 86 increased anxiety is nurse to the active.
beats/minute apprehensio reduced to a woman/couple
Temp: 37oC n manageable
level.
Subjective data: 2. Urge the 2. Presence
● Verbalized, “Nurse 2. Verbalized part/support provides 2. Recognition and
nibuto na akong awareness of person to continuing effective
tumatob, ma okay feelings of remain with the emotional verbalization of
rami sa akong bata anxiety. woman as support if this is anxiety of the
ani?” much as culturally mother.
● Verbalized, “Nurse possible acceptable and
nabalaka ko paras 3. Identify healthy agreed to by 3. Performed
akong bata ug ways to deal the anesthesia breathing
akong kaugalingon with and care provider. techniques and
kay pinakauna express anxiety. relaxation
paman gd nako 3. Maintain eye 3. The presence exercises
wala ko kabalo contact during of caregivers
unsay buhaton” 4. Use preoperative wearing masks 4. Support person
resources/supp procedures may be anxiety actively
ort systems producing. Eye participates in
effectively. contact, when the discussion
possible, and provides
provides emotional
support. support for the
birthing mother.
4. Include the 4. Ignoring the
woman/partner woman is
in depersonalizing
discussion/conv and increases
ersation in the anxiety.
operating room
5. Helps to
5. Encourage reduce anxiety
use/continuati and enables
on of client to
breathing participate
techniques actively.
and relaxation
exercises.
6. Enhances
6. Provide client’s sense
opportunities of control even
for client input though much
into decision- of what is
making happening
process may be
beyond her
control.
CUES/EVIDENCES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Objective data: After 1 hour of 1. Assess FHR 1. Detects After 1 hour of
● Risk for rendering nursing changes severity of rendering nursing
● Maternal vital impaired care, the fetal baby during a hypoxia and care, the fetal baby
signs: gas and birthing mother contraction, possible and birthing mother
BP:110/90 exchange will remain free noting cause. The remain free from
Maternal r/t cord from impaired gas impaired gas
decelerations fetus is
compressio exchange as exchange as
Pulse rate: 86 and vulnerable to
n as evidenced by: evidenced by:
beats/minut accelerations. potential injury
evidenced
es by low fetal 1. Will display during labor,
Temp: 37oC heart rate. FHR and beat-to- owing to 1. Displayed
beat variability situations that an FHR of
● Fetal vital within normal reduce oxygen 135 BPM
signs: limits. levels, such as with no
FHR: 100 bpm cord prolapse, abnormal
● Umbilical cord prolonged beat-to beat
compression head Variability
2. Will be free of
diagnosed by adverse effects of compression,
2. Amniotic
means of hypoxia during or fluid
ultrasound labor uteroplacental presents no
insufficiency. color, no
3. Maternal vital unusual
signs are within odor, and
Subjective data: within
normal values
2. Note and 2. In a vertex normal
● Mother amounts.
verbalizes“Wala 4. Absence of record color, presentation,
na kaayo ko nonreassuring amount, and prolonged
odor of hypoxia 3. Maternal
kabati sa paglihok FHR patterns vital signs:
sa ako anak” (late amniotic fluid results in
BP: 120/ 80
decelerations, and time of meconium- HR: 78
severe variable, membrane stained Temperatur
absent variability, rupture. amniotic fluid e: 37
etc) owing to vagal degrees
stimulation, celsius
which relaxes
the fetal anal 4. There is no
sphincter. sign of late
Hydramnios deceleration
may be s, severe
variable,
associated
and absent
with fetal variability in
anomalies the FHR
and poorly
controlled
maternal
diabetes.
3. Monitor 3. Decreased
maternal cardiac
heart rate and output or
blood maternal
pressure hypotensio
every hour n can
and as result in
needed or per decreased
hospital blood flow
protocols or to the
physician's placenta.
order
4. Reposition 4. Changing
the client positions to
the side or
knee-chest
can relieve
pressure
on the
umbilical
cord,allowi
ng more
blood to
flow
through it.
Repositioni
ng also
prevents
supine
hypotensio
n, which
decreases
blood flow
to the
placenta.
5. If non 5. Oxytocin
reassuring intensifies
patterns uterine
occur, provide contraction
8-10 L/min by , which
mask decreases
placental
blood flow
.
6. Notify the 6. Allows
health care additional
provider of uterine
nonreassurin contraction
g FHR , which
patterns decreases
placental
blood flow.
