عدد المساهمات : 354
تاريخ التسجيل : 30/04/2011
|موضوع: Nursing care plan لحالات الولادة السبت أبريل 30, 2011 1:51 am|| |
Normal labor Nursing Diagnosis 1: Powerlessness related to painful contractions and duration of labor Goal: Client will demonstrate that she feels some control over the labor process after 30 minutes. Outcome
Evaluation: Client expresses preferences for position and techniques to
control pain; asks questions about her progress and states feelings
about what is happening. Interventions
Allow her to be out of bed walking or sitting up in bed.
Assess couple for contributing factors related to feelings of loss of control.
Assist with using controlled breathing exercises and position changes.
Reinforce information learned in childbirth education classes.
Slowly and clearly explain the events and changes occurring with the active stage of labor.
Inform the couple of things that can and cannot be controlled.
Reassure, as appropriate, that labor is proceeding without problems.
Provide continued emotional support throughout labor and provide privacy as appropriate.
Encourage the husband to continue to actively support his wife.
Administer analgesia and anesthesia according to the policies. Nursing Diagnosis 2: Risk for infection related to early rupture of membranes.Goal: Client will remain free of signs and symptoms of infection. Outcome
Evaluation: Temperature remains below 100.4°F (38°C); pulse,
respirations, and blood pressure remain within acceptable parameters of
client’s baseline values. Interventions
Obtain vital signs, at least every 1 to 2 hours and report any temperature above 100.4°F (38°C).
Perform perineal care frequently, especially after each voiding and any bowel movements.
Change bed linens and pads as soon as they become soiled or moist.
Use aseptic techniques when performing pelvic examination.
Administer IV fluids as ordered to maintain fluid balance.
A woman whose membranes have ruptured should lie on her side until a
fetal monitor shows good baseline variability and no variable
decelerations or she has been checked to cofirm the head of the fetus
is well engaged to prevent the umbilical cord prolapse into the vagina
Give the cleansing
Nursing Diagnosis 3: Risk for ineffective breathing pattern related to breathing exercises
. Outcome Identification: Client will not experience hyperventilation when using breathing techniques during labor
Evaluation: Client’s respiratory rate is within normal limits; skin
pink, cool, and dry. No reports of lightheadedness or tingling/numbness
in extremities. Intervenions
To halt hyperventilation, the woman should keep a paper bag nearby when
doing breathing exercises. She can ward off symptoms of
hyperventilation by breathing in and out into the paper bag. This
causes her to rebreathe the carbon dioxide she exhales, thus replacing
the carbon dioxide lost.
If a paper bag is unavailable, she can use her cupped hands instead.
Prevent hyperventilation by making certain that when the woman is
breathing rapidly she is not hyperventilating, and that she ends all
breathing sessions with a long cleansing breath to help restore carbon
dioxide balance. Nursing Diagnosis 4: Anxiety related to stress of labor.
[COLOR="SeaGreen"]Goal: Client will manage the stress of situation with positive coping mechanisms.[/
COLOR] Outcome Evaluation: Client states that she feels
somewhat in control of her situation; she and her support person
express confidence in themselves and health care personnel. Interventions
Help the woman to perceive labor clearly and providing the opportunity
for her partner to provide support as well as being personally
available to provide support to the woman and her partner throughout
the labor process.
Offer Support. There is no substitute for personal touch and contact as a way to provide support during labor.
Patting a woman’s arm while telling her that she is progressing in
labor, brushing a wisp of hair off her forehead, wiping her forehead
with a cool cloth— help to convey concern. Nursing Diagnosis 5: Risk for fluid volume deficit
related to prolonged lack of oral intake and diaphoresis from the
duration of labor Goal: Client will not experience fluid volume deficit during labor. Outcome Evaluation: Client states that she does not feel thirsty; voids at least 30 mL/h every 2 to 4 hours. Interventions
Limit the amount of oral fluid or food intake during labor to ice chips
or lollipops to prevent aspiration if, in an emergency, general
anesthesia administration should be necessary.
Provide frequent mouth washes and apply a cream to her lips.
Allow her to suck on hard candy or ice chips relieve this discomfort.
Women in prolonged labor may need additional fluid and caloric intake
to prevent secondary uterine inertia (a cessation of labor
contractions) and generalized dehydration and exhaustion.
If all oral fluids are contraindicated by the birth plan, intra-venous
glucose solutions may be administered to maintain caloric reserve.
هــذا كل اللــي عندي ، وتــرى هذا من جهــدي ، وان شـاء اللهـ اي شي جديد راح انزلهـ ع طوووول
والاهـــم الافــادة للجميــع
دمتــم بحفظ الرحمن
عدد المساهمات : 354
تاريخ التسجيل : 30/04/2011
|موضوع: رد: Nursing care plan لحالات الولادة السبت أبريل 30, 2011 1:51 am|| |
For most women, childbirth is a normal, healthy process for which women
have been uniquely designed. However, in about 25 % of pregnancies, a
deviation from normal presents a threat to maternal and fetal
The complications addressed in this lecture include dystocia, preterm labor, post term pregnancy, and multiple gestation. Nursing diagnosis: High risk for fatigue related to prolonged labor.
Nursing goal: Client will maintain adequate energy for continued labor.
Start IV glucose.
Give her lollipops or hard candies to suck.
Encourage breathing exercises.
Promote comfort - Give back rubs, Change sheets, Use cool wash cloths.
To prevent hypotension and improve blood supply to the uterus encourage side lying position.
Encourage voiding every 2 hours.
Nursing diagnosis: High risk for fluid volume deficit R/T length of labor and (potential) nausea and vomiting.
Nursing goal: Client will maintain adequate fluid and electrolyte balance during labor.
Test each voiding for glucose, protein, acetone and specific gravity.
Monitor IV intake and urine output
High risk for fetal injury related to undetected development of pathological retraction ring.
Goal: Fetal status will remain within normal parameters.
Observe the woman’s abdomen for the development of pathologic retraction ring.
Prepare and give an intravenous injection of morphine or give inhalations of amyl nitrite.
Fetal scalp blood sampling. A pH below 7.25 indicates fetal distress.
Prepare for Cesarean birth, if not relieved.
Prepare for manual removal of placenta under GA if placenta is
Nursing diagnosis: Fear R/T lack of knowledge regarding induction of labor.
Goal: Client will demonstrate acceptance of induction procedure.
Inform her that her contractions become stronger and she will experience more pain with contractions.
Stay with the client.
Inform the progress of labor.
وسلامتكــم واتمنــى الافاده للكل
واي احد عندهـ طلب عن NCP يخص امراض الولادة والاطفال ، بس يكتبلــي
تحت رد ومن اعنــونــي