A Sample Nursing Care Plan for a patient with Diabetes MellitusFull description
Deskripsi lengkap
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ncpFull description
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Assessment
Cues:
Diagnosis Risk for
Premature
Maternal Injury
cervical dilation
related to Subjective: “Nakikita ko may premature kasamang dugo cervical dilation sa napkin ko pagas manifested ihi ko” as by threatened verbalized by the client abortion Objective: - blood in urine -G4P0 (0210)
Nursing Implication
previously termed as incompetent cervix refer in a cervix that dilates prematurely and therefore cannot hold a fetus until term that increase
Planning
Interventions
Goals:
Independent:
After 8 hours of nursing intervention, the patient will experience no vaginal bleeding.
1.
Monitor vital signs closely
2.
Note presence of vaginal bleeding, leaking amniotic fluid, or uterine contraction
the risk to the mother injury
V/S taken as follows: T: 36.7 P: 110 R: 21 Bp: 110/60
Maternal & child health nursing: care of the childbearing & childrearing family: Chapter 21 pg. 563 by Adelle Pilliteri”
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3.
Notify physician of abnormal findings or signs of labor
4.
Assess for presence of contraindications for cerclage procedure
5.
Review implication of cerclage procedure on outcome of delivery at term.
Rationale
Changes in vital signs (e.g., elevated temperature or pulse, decreasing BP) may indicate infection or shock Vaginal bleeding other than slight spotting may be sign of cervical dilatation. Leaking membranes may herald impending delivery and place client at greater risk for infection.
Prompt intervention lessens likelihood of complications
The procedure is not done if vaginal bleeding or cramping is present, if membranes are ruptured, if cervical dilation greater than 3 cm occurs, or if the diagnosis of cervical dysfunction is in question because situation has progressed and spontaneous abortion is inevitable.
A cesarean birth may be planned if the suture is left intact, or the suture may be removed, allowing a vaginal delivery. Note: Scar tissue may interfere with normal intrapartal cervical dilation and effacement
A common side effect is
Evaluation After 8 hours of nursing intervention, the patient have no vaginal bleeding. Goal was met.