Nursing care plan
I need help from a nurse
You should write a care plan about this case (the plan should be arranged in order of priority ). Don’t forget to put assessment in the care plan
A 22-year-old G3P2 woman at 40 weeks’ gestation complains of strong uterine contractions. She denies leakage of fluid per vagina. She denies medical illnesses. Her antenatal history is unremarkable. On examination, the blood pressure (BP) is 120/80 mm Hg, heart rate (HR) is 85 beats per minute (bpm), and temperature is 98°F (36.6°C). The fetal heart rate is in the 140 to 150 bpm range. The cervix is dilated at 5 cm and the vertex is at –3 station. Upon artificial rupture of membranes, fetal bradycardia to the 70 to 80 bpm range is noted for 3 minutes without recovery.
Please help me. The deadline for submitting the assignment is today .
Expert Solution Preview
In this nursing care plan, the priority of care for a 22-year-old pregnant woman experiencing strong uterine contractions will be addressed. The case involves a G3P2 woman at 40 weeks’ gestation who complains of uterine contractions, denies leakage of fluid, and has a history of unremarkable antenatal visits. During examination, it is noted that her blood pressure, heart rate, and temperature are within normal limits, and the fetal heart rate falls within the expected range. However, after artificial rupture of membranes, fetal bradycardia lasting for 3 minutes is observed. This care plan will focus on addressing the immediate concerns and ensuring the well-being of both the mother and the fetus.
Nursing Care Plan:
– Assess uterine contraction pattern, intensity, duration, and frequency.
– Monitor maternal vital signs including blood pressure, heart rate, and temperature.
– Continuously monitor fetal heart rate.
– Evaluate cervical dilation, effacement, and fetal descent.
– Assess maternal pain level and pain management techniques.
– Monitor amniotic fluid color, amount, and odor.
– Evaluate the presence of any vaginal bleeding or discharge.
2. Analysis/Priority Identification:
Based on the given case, the following priorities are identified:
– Fetal well-being
– Maternal pain management
– Progression of labor
– Identification of any complications
3. Nursing Diagnoses:
1. Risk for fetal distress related to fetal bradycardia
2. Acute pain related to uterine contractions
3. Ineffective coping related to labor process
i. Fetal Well-being:
– Notify the healthcare provider immediately about the fetal bradycardia incident.
– Administer oxygen to the mother to optimize fetal oxygenation.
– Initiate continuous fetal heart rate monitoring.
– Assist with positioning the mother to the left side to increase placental perfusion.
– Prepare for emergency cesarean section if fetal distress persists.
ii. Maternal Pain Management:
– Offer non-pharmacological pain relief methods (e.g., relaxation techniques, breathing exercises).
– Administer analgesic medication or epidural anesthesia as prescribed.
– Encourage the use of heat or cold therapy as appropriate.
– Provide emotional support to help the mother cope with labor pain.
iii. Progression of Labor:
– Promote spontaneous labor progress by encouraging walking or position changes.
– Monitor cervical dilation and effacement.
– Encourage the use of hydrotherapy (e.g., warm shower or sitz bath) to promote relaxation and pain relief.
– Support the mother during the pushing stage of labor.
iv. Identification of Complications:
– Continuously assess for signs of infection (e.g., fever, foul-smelling discharge).
– Monitor for signs of excessive bleeding or abnormally prolonged labor.
– Report any abnormalities or changes in maternal and fetal conditions promptly.
– Monitor fetal heart rate and document trends and changes.
– Assess the effectiveness of pain management interventions.
– Monitor progress in cervical dilation and descent of the fetus.
– Continuously reassess maternal and fetal well-being.
It is crucial for the nurse to collaborate with the healthcare team, maintain clear communication, and promptly report any concerning findings. By following this care plan, the nurse can prioritize the well-being of both the mother and the fetus, ensuring a safe and satisfactory labor process.