Case Pres With Ncp @ Pnp

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING BATCH 2010

CASE PRESENTATION BSN048 GROUP 190-B Rieza, Wendy Ann M. Salamat, Neoma Syrilla T. Santos, Janessa Joy S.

Prof. Jeannie Patrimonio

Introduction: The client chosen for this case is R.T.C NORD, female, 26 years of age,. Her religion is Roman Catholic She was born on July 24, 1981 in Tuguegarao City. And married to PO1 T.C PNPSAF B96L28 from Paliparan Dasma, Cavite. Admitted to OBward by admitting officer/ admitting physician PSUPT Guiatani on 21 2330H July 2008, room number 3 with hospital no. 04-01-35. Is Dependent, ambulatory, First type of admission with

Direct source of

Admission. Has admitting Diagnosis of G2P1 PU 23 4/7 weeks AOG, Pre Term Labor. R.T.C is accompanied by husband with cc of vaginal spotting or verbalized. LmP is February 22, 2008, EDC is November 29, 2008, RR of 21 cycles/min, BP 130/80mmhg with temp of 36.7 and cardiac rate of 78bpm.Conscious and coherent, with negative uterine contraction and positive on vaginal spotting. We chose this case because this case is more challenging among other cases that we’ve handled and there’s a lot to learn from this case. In addition to that, the diagnosis of the patient might be a threat to the fetus that needs to be focused on, assessed for nursing intervention to help prevent further complications. II Nursing History A. Past health History R.T.C 26 y/o G2P1 doesn’t have history on Hypertension, Diabetes mellitus, and asthma. She is diagnosed of hyperthyroidism during her first pregnancy on the year 2006 on PTV but stop after several weeks. B. History of Present Illness

R.T.C was admitted dependent, ambulatory, PU 23 4/7 weeks of AOG, Pre Term Labor. Consulted regarding thyroid problem, still for follow up of FT3 FT4 TSH. Undergone Transabdominal Ultrasound result revealed oligohyramnios (AFI- 1.7cm).

Discharge Plan Medication: Isoxsuprine tablet Q8H Inderal 10mg 1 tab BID MV (natalbes) tablet OD FC Fumirate tab (fumuim) OD Exercise: -CBR Treatment: -rest and sleep -medication -increase fluid intake Health Teaching:

Low levels of amniotic fluid can increase your risk of complications during labor. The main concern is that the fluid level will get so low that your baby's movements or your contractions will compress the umbilical cord. So Oligohydramnios can sometimes be treated with bed rest, oral and intravenous hydration, antibiotics, steroids, and amnioinfusion. It is advised to continue the increse of oral fluids, have bed rest and consult doctor as advised. Out Patient: -The patient should consult doctor/physician if there are complications after discharge for immediate action.

-The patient should follow the physicians order. Diet: Practice good eating habits. Just as important as what you eat is the manner in which you eat. Eat moderate proportions, eat at regular times and relax while you eat advised a low residue diet. Increase fluid intake to 2liters/day. Maintain a healthy lifestyle Walking during pregnancy is a great way to feel good and become more fit. Best Walking Tips While Before you get walking, learn some easy and sensible tips to make the most of your walk: 



 

Pregnant

Stand tall. Stand up straight and use your abdominal muscles to support your back. Practice relaxing your stomach, then pulling it back in so you get a feel for what it means to hold in your abs. If you're very pregnant, you may want to wear a maternity belt under your clothes for additional abdominal support. A maternity belt has is a wide band that goes under your tummy for support. You can buy one in a maternity store or catalog. Look ahead. Look at the ground a few steps ahead of you — not straight down (which strains your neck and hunches your shoulders) or far off into the distance (in case you have to dodge people or tackle tough terrain). Get into position. Keep your elbows close to your body, your shoulders back slightly, and your elbows bent. Hold your hands in light fists, as if you're grasping an egg. Start off small. Begin walking in short strides. Long ones can hurt your hips and pelvic area, which are loosened by hormones released during pregnancy.

Safety: Pregnancy Fitness Safety Tips Staying fit during pregnancy is an important part of feeling your best. If yours is a low-risk pregnancy, and your doctor approves, you can continue to exercise and derive health benefits even from mild-to-moderate fitness

routines. The American College of Obstetricians and Gynecologists recommends following these guidelines to ensure a healthy pregnancy — for you and your baby. • • • • • •

• • •

•

Stay consistent. Exercise regularly (at least three times a week) — not intermittently. Exercising three days a week is a good routine. Keep your fitness regimen in the mild-to-moderate range. Easy does it. Avoid activities that require jumping motions or sudden changes in direction because these may strain your joints and injure you. Watch your back. Don't exercise on your back after the first trimester. Also, avoid prolonged periods of motionless standing. Both actions can reduce blood flow to the uterus. Don't overexert yourself. Be aware that you have less oxygen available for exercise. Stop exercising when you become fatigued, and don't exercise to the point of exhaustion. Keep your balance. Avoid exercises that could cause a quick loss of balance or mild trauma to the abdomen. Eat a good diet. Be sure you eat an adequate diet that allows you to gain 25 to 35 pounds over the nine months. Most pregnant women require an additional 300 calories a day. If you exercise regularly, you will probably require more. Include plenty of carbohydrates in your diet, as pregnant women use up this fuel source more quickly during exercise than non-pregnant women. Drink up! Drink plenty of water to keep you hydrated and prevent overheating. Get comfortable. Wear comfortable, cool, and supportive clothing in layers that can be easily removed. Wear a bra that fits properly and supports your breasts. Keep cool. Be mindful not to become overheated, especially in the first trimester. According to the American College of Obstetricians and Gynecologists, overheating, especially in the first trimester, may be a contributing factor to the development of birth defects. Drink plenty of fluids before and during exercise, wear layers of "breathable" clothing, don't exercise on hot, humid days, and don't immerse yourself in a hot tub or sauna. Avoid certain sports. According to the Mayo Clinic, you'll want to avoid certain sports altogether while you're pregnant. These include activities at high altitudes and those that are associated with a risk of falling or colliding with another participant, such as horseback riding, climbing and snow and water skiing. Also, avoid scuba diving because there's a risk that your oxygen intake could be compromised, and diving can put pressure on your organs and baby.

Anatomy and Physiology Amniotic fluid is the nourishing and protecting liquid contained by the amnion of a pregnant woman. The amnion grows and begins to fill, mainly with water, around two weeks after fertilization. After a further 10 weeks the liquid contains proteins, carbohydrates, lipids and phospholipids, urea and electrolytes, all which aid in the growth of the fetus. In the late stages of gestation much of the amniotic fluid consists of fetal urine. The amniotic fluid increases in volume as the fetus grows. The amount of amniotic fluid is greatest at about 34 weeks after conception or 34 weeks ga (gestational age). At 34 weeks ga, the amount of amniotic fluid is about 800 ml. This amount reduces to about 600 ml at 40 weeks ga when the baby is born. Amniotic fluid is continually being swallowed and "inhaled" and replaced through being "exhaled", as well as being urinated by the baby. It is essential that the amniotic fluid be breathed into the lungs by the fetus in order for the lungs to develop normally. Swallowed aminotic fluid contributes to the formation of meconium.

Analysis of amniotic fluid, drawn out of the mother's abdomen in an amniocentesis procedure, can reveal many aspects of the baby's genetic health. This is because the fluid also contains fetal cells which can be examined for genetic defects. Recent research by researchers led by Anthony Atala of Wake Forest University and a team from Harvard University has found that amniotic fluid is also a plentiful source of non-embryonic stem cells. These cells have demonstrated the ability to differentiate into a number of different cell-types, including brain, liver and bone. Amniotic fluid also protects the developing baby by cushioning against blows to the mother's abdomen, allows for easier fetal movement, promotes muscular/skeletal development, and helps protect the fetus from heat loss. The forewaters are released when the amnion ruptures, commonly known as when a woman's "water breaks". When this occurs during labor at term, it is known as "spontaneous rupture of membranes" (SROM). If the rupture precedes labor at term, however, it is referred to as "premature rupture of membranes" (PROM). The majority of the hindwaters remain inside the womb until the baby is born.

Complications related to amniotic fluid Too little amniotic fluid (oligohydramnios) or too much (polyhydramnios or hydramnios) can be a cause or an indicator of problems for the mother and baby. In both cases the majority of pregnancies proceed normally and the baby is born healthy but this isn't always the case. Babies with too little amniotic fluid can develop contractures of the limbs, clubbing of the feet and hands, and also develop a life threatening condition called hypoplastic lungs. If a baby is born with hypoplastic lungs, which are small underdeveloped lungs, this condition is potentially fatal and the baby can die shortly after birth. On every prenatal visit, the obstetrician/gynaecologist should measure the patient's fundal height with a tape measure. It is important that the fundal height be measured and properly recorded to insure proper fetal growth and the increasing development of amniotic fluid. The obstetrician/gynaecologist should also routinely ultrasound the patient—this procedure will also give an indication of proper fetal growth and amniotic fluid development. Oligohydramnios can be caused by infection, kidney dysfunction or malformation (since much of the late amniotic fluid volume is urine), procedures such as chorionic villus sampling (CVS), and preterm premature rupture of membranes (PPROM).

Oligohydramnios can sometimes be treated with bed rest, oral and intravenous hydration, antibiotics, steroids, and amnioinfusion. Polyhydramnios is a predisposing risk factor for cord prolapse and is sometimes a side effect of a macrosomic pregnancy. Hydramnios is associated with esophageal atresia. Amniotic fluid is primarily produced by the mother until 16 weeks of gestation. COLOR OF AMNIOTIC FLUID WITH CONTRAINDICATIONS GREEN - neco state YELLOW - hemolitic deisease BROWN infection

III. Activities of daily living Activities of Daily Living

Before Hospitalization

During Hospitalization

Analysis & Interpretation

NUTRITION

The client verbalized: “ Nakakain ko gusto ko, lalo na mga gulay. Madalas akong kumain ng meat.” “ Hindi ako masyadong umiinom ng tubig dati, mga 1 liter lang.”

“ Minsan ayoko ng binibigay nilang ulam kaya nagpapabili ako sa labas. Madalas sabaw, atay, karne, at gulay pero hindi na ako mayadong kumakai ng isda ngayon kasi ayoko yung amoy.” “ Madami akong uminom ng tubig ngayon kasi yun ang inadvice sa’kin. Mas madami pa sa 2 liters naiinom ko sa isang araw.”

She doesn’t have any problems regarding her nutritional intake. She increased her oral fluid intake to improve her condition being diagnosed with oligohydramnios. Nutrition is vital aspect of the health of women at all ages and is particularly important during the childbearing years because it affects the health and development of the child. An adequate food intake consists of a balance of essential nutrients: water, carbohydrates, proteins, fats, vitamins, and minerals. Nutrition during pregnancy has implications for both the mother and the fetus. The mother’s nutrition before pregnancy is also important for the health of the fetus. The usual recommendations for adults are to drink 8-10 cups (1 cup=8oz=237 ml) of water per day, or 30 ml/kg of body weight, with a minimum of 6 cups (1500 ml) for small individuals. Because the pregnant woman’s blood volume is expanding water and other fluids should be increased. The pregnant woman needs an additional daily 30 ml of water per kilogram of body weight gained.

ELIMINATION

EXERCISE

“Nakakadalawang beses akong dumumi sa isang araw.” “Madalas ako umihi kapag napaparami inom ko,kadalasan ay sampung beses o di kaya 15.”

“Dalawang beses dn akong dumumi ditto sa isang araw.” “Bawat oras, umiihi ako sa isang araw.”

“hindi ako nageexercise pero naglalakad naman ako paminsan- minsan”

“kadalasan nakaupo at nakahiga lang ako dito.”

The patient’s bowel movement is normal and there is an increase in her urinary elimination but it is still normal because there is an increase in her fluid intake. Elimination of the waste products of digestion from the body is essential to health. There is an increased urine flow and volume as well as bowel movement for pregnant women because of their increased fluid intake and nutritious foods intake and the supplements they needed. The client is not capable of rigid exercises because of her condition. She is only allowed to have a complete bed rest. Exercise to stay regular like walking three to four times per week for 2030 minutes is recommended. Regular exercise is essential for healthy functioning of major body systems. The benefits of exercise on these system follows: Musculoskeletal- size, shape, tone & strength of muscles are maintain with mild exercise and increases with strenuous exercises. Cardiovascular- increase heart rate. Respiratory- ventilation increases.

HYGIENE

SUBSTANCE USE

“dalawang beses sa isang araw akong maligo.” “3 beses magtoothbrush” “lagi kong pinananatiling malinis katawan ko.” “wala akong bsyo, masama para sa baby ko.”

“ngayon lang lit ako nakaligo, puro pagpupunas lang dati.” “tatlong beses pa rin ako nagsisiplyo.”

“wala akong bisyo”

Gastrointestinal- improves the appetite and increase gastrointestinal tract tone, facilitating peristalsis. Metabolic- elevates metabolic rate. Urinary- promote efficient blood flow, body excretes waste more effectively. Psychoneuologic- produce a sense of well-being and improes tolerance to stress. The patient was not allowed to take a bath before that’s why she didn’t meet the standards regarding her hygiene particularly in taking a bath.

The patient doesn’t take any drugs or substances that may affect her health and the fetus inside her. Women who are pregnant should abstain from consuming alcohol. Excessive, chronic ingestion of alcohol can impair nutrition. Excessive alcohol intake may limit the necessary intake of calories and nutrients. It may also affect the health and development of the growing fetus inside her womb. Newborn born to mothers who

SLEEP & REST

“mga anim na oras tulog ko dati.” “sa hapon nagpapahinga din ako ng mga isang oras..”

“Minsan napuputol pagtulog ko, pero kadalasan limang oras tulog ko.”

smoke have lower birth weights, a higher incidence of SIDS, a higher incidence of premature birth and are more likely to have episodes of apnea. Large doses of illicit drugs or street drugs can cause low birth weight or fetal distress. The client has an irregular sleeping pattern and does not meet the normal range of sleeping hours for pregnant women. Rest and Sleep are essential for health. People who are ill frequently require more rest and sleep than usual same with those pregnant women who needs more rest.

IV. Physical Assessment Body Parts General Appearance

Temperature Pulse Rate Respiratory Rate

Normal Findings Varies with lifestyle Relaxed, erect posture, coordinated movement Clean. Neat No body odor Healthy appearance 37۫ C (98.6 F) 80 bpm (60-100 bpm) 16 bpm (12 -20 bpm)

Actual Findings -the client wears a clean clothes, sitting on bed -conscious, coherent - no body odor

Analysis NORMAL

37۫ C 82 bpm 20 bpm

NORMAL NORMAL NORMAL

Posture

Mental Status: Verbal Behavior

Hair

Skin

Erect posture and an active purposeful stride suggest a feeling of wellbeing. -Cooperative -Client’s response appropriate to situation -Quantity, quality and organization of speech is understandable, moderate pace, exhibits thought association -thoughts are in logical sequence, makes sense and has sense of reality. -can be black, brown, or burgundy in color; free from lice, nits and dandruff -maybe thick or thin; evenly distributed -silky, resilient hair -no infections or infestation -color varies from light to deep brown -no edema, abrasions, pallor, cyanosis and lesions -moisture in skin folds and axillae -good skin turgor

-Sits in erect posture -active

NORMAL

-the patient was able to answer well -has an organized thoughts -she is cooperative

NORMAL

-black color of hair -her hair is evenly distributed -smooth in texture

NORMAL

Color: slightly dark skin Feel: warm to touch Turgor: good skin turgor -there is a presence of edema

There is a presence of edema because of the IV insertions.

V. Course in the Ward

R.T.C was admitted to Ob ward on July 21, 2008 with the BP of 130/80, temperature of 36.7’C and 23 4/7 weeks AOG. Diet is DAT. Undergone CBC and UA results were normal. Given IVF of D5 W 1L +8amps duvadilan to run for 15ugtts/min after checking BP and CR. Given the medicine Ampicillin 1g IV q’6 ANST, Natalbes 1tab OD, Femiron 1tab OD, Folart (folic acid) 1 tab, calcium 1tab q’12. R.T.C undergone transvaginal ultrasound. Monitor V/S every shift. 22 2100H July 2008. Continue duvadilan drip and increase OF 2L/day. Dx asymptomatic FT3 FT4 FST (047/2008) normal. Undergone transabdominal ultrasound at 24 1500H July 2008 for amniotic fluis quantification resulted oligohydramnios, intramural myoma nodule upper anterior (3.5x2.0cm) with note of multicystic left kidney, suggested congenital anomaly scan at 24 weeks AOG by physician. Advised increase of Oral Fluids to 2L/day. 25 0700H July 2008, IVF to follow are D5LR 1L fast drip 300cc then regulate to 6 hrs, D5NM 1L X 6hours, D5LR IL X

6hours. To discontinue ampicillin IV and duvadillan drip to consume and then shift to duvadilan tablet BID. Advised to maintain in lateral derubitus position. Monitored V/s FHT and recorded.1100H permitted to take a bath. Last Bp taken

was

110/70 temperature

is

37’C RR-20, PR-

Immunology

Result

Unit

FT3 (ECLIA) FT4(ECLIA) TSH(ECLIA)

3.710 13.59 2.370

Pmol/L Pmol/L uIU/ml

Referenceranges 2.80-7.10 12-22 0.27-4.20

Analysis?

82. 26 0725H July 2008, R.T.C is advised on a low residue diet, still increase of fuid intake and to continue IV series D5LR5 1L x 6 hours, D5NM 1L x 6 hours, D5NR IL x 6 hours, D5NM IL x 6 hours, pt may turn on Lest and right. 20 July 2008 undergone transvaginal ultrasound at AGRA. 30 1930 July 2008 for congenital scanning @ 28 weeks (august 12, 2008) or on next ultrasound. Vital sign ans FHT monitored and recorded.

Laboratory and Diagnostic Examinations Result

Urinalysis Result 07/21/08 Macroscopic exam Color Transparency Reaction Specific gravity Sugar Protein Microscpic exam RBC Pus Cell Squamous Ephitilial cells

result

Norm

straw S.I turbid Acidic 1.005 Negative Negative

Straw, amber clear Acidic 1.005-1.025 Negative Negative

0-2 0-2 few

0-1hpf 0-2/hpf

Hematology 04/30/08 Leukocyte count Leukocyte diff. count Neutrophils

Pt Value 9.8 x10 9/L

Reference range 4.5-11.0

0.67

0.35-0.65

Eosinophils Lymphocytes

0.03 0.30

0.00-0.05 0.20-0.40

Hemoglobin hematocrit

110g/l 0.36 vol. frac

120-160 0.37-0.41

Ultrasound 1 Obstetrics Ultrasound Report 24 July 2008 Second and third trimester ultrasound report Final impression: Cephalic presentation, live singleton No previa Posterior placenta location] Amniotic fluid volume: oligohydramnios (AFI=1.7cm) Placental grade: grade 1 Pregnancy Uterine, 21 wks 3 days AOG by fetal biometry Intramural myoma nodule, upper anterior (3.5 x 2.0) With note of multicystic left kidney Suggest congental anomaly scan at 24 weeks AOG.

Ultrasound 2 Obstetrics Ultrasound Report 7/28/2008

2nd and 3rd trimester Number of fetus: 1 Presentation: breech Amniotic fluid volume: 39 (2vp) Q1- 1.8 Q2- 2.1 Placenta location: fundus Fetal Biometry BPD - 52mm 21weeks 4days HC - 192mm 21weeks 3days AC - 163mm 21weeks 1day FL - 35mm 22weeks 1day AV Sonar age 21 weeks 4 days Estimated date of delivery: 12/04 Wstimated fetal weight. 429 grams Remarks: The amniotic Fluid index has improved slightly., but generally scanning showed still with oligohydramnios

Generic Name

Dosage/ Frequency

Classificatio n

Indications

Contraindicat ions

Side effects

Nursing Consideratio ns

Cues OTransabdomina l Ultrasound resulting in Oligohydramni os

Nursing Diagnosis

Analysis

Planning

Risk for Fetal Injury related to cord compression secondary to decreased amniotic fluid as manifested bu Trans abdominal ultrasound result.

At risk of fetal injury as a result of environment al conditions interacting with the individual’s adaptive and defensive resources

Goal: After 4 hrs of nursing intervention, the client will verbalize understanding of individual factors that contribute to possibility of fetal injury and take steps to correct situation

Intervention

Rationale

Objective: After 4 hrs of nursing intervention, the client will: 1

. Verbalize the definition and possible causes of oligohydramnios

2 . Verbalize complication and effect of oligohydramnios to the baby

3. Abide to the doctors order and health teachings.

1. Assess clients ability to understand teaching

2. Provide a comfortable quite setting for teaching and invite family to participate

3. Provide written information on oligohydramnios about its causes, effect and complication 4. Provide information on

1. Assessment provide info to guide planning an individualized teaching program to ensure the clients understanding 2. Intervention decrease distraction and promote learning; family may reinforce teaching and help client comply

3. Accurate info encourages compliance and written resources for later review and self paced 4. To enhance

Evaluation All the Nursing intervention rendered to the client were appropriate, efficient , effective and adequate for the clients condition. Through this interventions the client was been able to verbalize understandin g of individual factors that contribute to possibility of fetal injury and take steps to correct her situation

Cues

S- “ Ang alam ko lang pwede malaglagan ng bata pag ganun eh” as stated by the client -“Sabi nila pwede daw akong manganak ng wala sa kabuwanan pag ganun. Yun lang ang alam ko” as stated by the client -“ Hindi naman ako naghihilab,gu magalaw lang yung baby sa tiyan ko” as stated by the client O- less anxiety

Nursing Diagnosis

Analysis

Planning

Deficient Knowledge regarding Preterm labor prevention related to unfamiliarity with preterm labor

Absence or Deficiency of cognitive information related to specific topic (preterm labor prevention)

Intervention

Rationale

Goal: After 4 hrs of nursing intervention, the client will verbalize increase knowledge about preterm labor Objective: After 4 hrs of nursing intervention, the client will:

1. 1. Describe signs and symptom of preterm labor 2. Describe steps to take to avoid preterm labor 2.

1 . Assess client’s risk factor for preterm labor and ability to understand teaching

2. Provide a comfortable quite setting for teaching and invite family to participate in session 3. Assist clients understanding of the risks of preterm labor and birth for her baby.

4. Help client to identify Braxton-

1. Assessment provide to guide planning an individualized teaching program to ensure client understanding. 2. Interventions decrease distractions and promote learning; family may reinforce teaching and help client comply. 3.Some clients may believe that preterm infants have few problems or that 7 month babies do better than 8 month gestations(old wives tale)

4. Assisting empower the client to recognize

Evaluation All the Nursing intervention rendered to the client were appropriate, efficient , effective and adequate for the clients condition. Through this interventions the client was able to verbalize understandin g about s/s of preterm labor and what’s its possible prevention

Cues

Nursing Diagnosis

Analysis

Planning

Intervention

Rationale

Evaluation

O- doctors order to have complete bed rest with out bathroom privileges

Deficient Diversional Activity related to prescribed complete bed rest without bathroom privileges secondary to preterm labor

Decreased stimulation from recreational or leisure activities.

Goal: After 4 hrs of nursing intervention, the client will verbalize examples of satisfying activities within personal limits Objective: After 4 hrs of nursing intervention, the client will: 1. 1. Be motivated and stimulate client involvement in solution 2. Promote wellness

1 .Determine ability to participate in activities that are available 2.Acknowledge reality of situation and feelings of the client

3. Provide for physical as well as mental diversional activities

1. Presence of depression, problem of mobility, protective isolation, or sensory deprivation may onterfere with desired activity 3. Interventions decrease distractions and promote learning; family may reinforce teaching and help client

All the Nursing intervention rendered to the client were appropriate, efficient , effective and adequate for the clients condition. Through this interventions the client was able to verbalize understandin g about s/s of preterm labor and what’s its possible prevention

comply. 4. encourage mix of desired activity( e.g., music, reading, news program etc.)

5. Accept hostile expressions while limiting aggressive acting-out behavior

6. Make appropriate referrals to available support groups, hobby clubs, service

4.Some clients may believe that preterm infants have few problems or that 7 month babies do better than 8 month gestations(old wives tale)

5. Assisting empower the client to recognize mild uterine contraction. Many women are unaware that Braxton-Hicks are contraction even if they are not painful

6. Teaching promotes self care and

organizations

assessment skills. The fundus is the thickest part of the uterus where contractions are most easily felt.

6. Teaching promotes awareness of sensations of contractions and fetal movement. Journal provides a written record of activity.

7. Teaching empowers client to recognize subtle signs of preterm labor. Client may not experience contractions as

such.

8. Dehydration or a distended bladder may increase uterine irritability/activit y.

9. Instruction avoids activity that may cause the release of oxytocin from posterior pituitary gland. Semen contains prostaglandins that may affect uterine activity. 10. Instruction allows client to have some evaluation of preterm labor

Prioritization:

Nursing Diagnosis Risk for Fetal Injury related to cord compression secondary to decreased amniotic fluid as manifested bu Trans abdominal ultrasound result.

Rank 1

Justification It is a life threatening situation that needs immediate interventions.

Deficient Knowledge regarding Preterm labor prevention related to unfamiliarity with preterm labor

2

It does not need immediate interventions because our nursing intervention is only to provide information about preterm labor.

Deficient Diversional Activity related to prescribed complete bed rest without bathroom privileges secondary to preterm labor

3

This nursing Dx is least addressed because it focuses on psychomotor and it is not that life threatening.

ECOLOGIC MODEL

A. Hypothesis Based on the gathered data and information, we presume that the fetus is the host, the mother is the agent and the amniotic fluid is the environment. The mother acquired oligohydramnios because of certain factors such as decrease fluid intake (1 liter/day) B. Predisposing Factors

Agent

We chose Agent-Host-Environment Model since according to her diagnosis, too little amniotic fluid . This model is composed of three dynamic, interactive elements. The Agent, a factor (biologic, chemical, physical, mechanical, psychosocial) that must Environment be present or absent for an illness to occur. In this case, the Environment Host agent will be the mother, Second, the host which is the fetus, a st living being capable of being infected or affected by the agent. Lastly, the environment, wherein everything external to the host that makes illness more or less likely which is the amniotic fluid. We know that when a single component of this model will be altered, a disease or illness will take place.

C. Conclusion and Recommendation After analyzing the client’s predisposing factors that affect her condition, we conclude that the agent is the primary factor that causes her to acquire her present condition. As stated by the client, she has inadequate gluid intake before admission to the hospital.

As for the recommendation, we advise the client to continue her ongoing treatment for the promotion of her wellness and her baby’s wellness and reduce further complication.

PATHOPHYSIOLOGY (Can be associated) Fetal abnormalities (growth restricted

fetuses)

Redistribute blood flow away from their kidneys, Failure of fetal kidney development Blocked urinary excretion

Decrease in fetal urine production

Decrease in amniotic fluid volume (oligohydramnios) Contractions occur or movements of the fetus in the womb

Compression of the umbilical cord Poor fetal lung development (pulmonary hypoplasia), malformations may result to compression of fetal parts, fetal death