REVIEW PROCESS FOR NURSING intrapartum complications
A. Assessment
1. Health History
a. Get a description of symptoms that include awitan, duration, location and trigger factors or events. The main signs and symptoms may include:
(1) The fluid which emanates suddenly from the vagina
(2) Each lot of vaginal bleeding
(3) The presence of uterine contractions with or without abdominal pain
(4) Decrease in fetal movement
b. Dig a mother and a family history of whether there are risk factors for intrapartum complications.
(1) maternal risk factors include:
(A) age younger than 18 years
(B) History of preterm birth
(C) poor obstetric history
(D) Multiple Pregnancy
(E) Hidramnion
(F) Smoking
(G) Hygiene bad
(H) poor nutrition
(I) Employment
(2) family risk factors include:
(A) History of diabetes
(B) history of birth complications in other family members.
c. Assess the family response to pregnancy, delivery of high risk, and possible crisis situations.
d. Assess the emotional connection a mother, father, and families and the possibility of perinatal loss and grief.
2. Physical examination
a. Vital signs
(1) Measure the maternal blood pressure, pulse, and breathing in the event of leakage of fluid or vaginal bleeding to assess the existence of shock.
(2) Measure the temperature of the mother to identify whether there is infection.
(3) Monitor the fetal heart rate to determine the status of the fetus.
b. Inspection
(1) Inspection of the output characteristics of the vagina on the perineum. Observations of color, odor, consistency, and the number of output vagina.
(2) Observation of the size and shape of the uterus.
(3) Inspection is there any sign of abnormal placenta visually.
c. Palpation
(1) Monitor the activity of the uterus to determine the progress of labor.
(2) Evaluation of cervical readiness for labor or progress in labor. Do not perform vaginal examination if there is bleeding.
3. Laboratory tests and diagnostic examinations
a. Ultrasound is used to determine the status of the fetus, knowing the location of the placenta, and determine the volume of amniotic fluid.
b. Kleihauer-Betke test or blood test fetal cells used to determine whether blood cells are the mother or fetus.
The cells remained colorless mother with staining. Fetal cells into a purple-pink when stained.
c. Nitrazin test paper and the fencing is used to determine whether there is rupture of amniotic bag. Paper nitrazin change color to green-blue when there is amniotic fluid. On microscopic examination of fluid samples, a ferning pattern, resembling the ice on the window, looking at the glass object. This is characteristic of a high fluid estrogen.
d. Monitoring of electronic uterus would indicate the presence of uterine contractions.
e. A complete blood count will record the existence of anemia or infection.
B. Nursing diagnosis.
In addition to the specific diagnosis of complications, the following are common nursing diagnoses for client care intrapartum high risk:
1. Anxiety
2. Fear
3. Ineffective family coping: disturbance
4. Adaptive grief
5. Impaired self esteem
6. Spiritual distress
7. Knowledge deficit
8. Painful
9. Risk of injury
C. Planning and identification results
1. Threats to the result of physical and emotional end of pregnancy the optimal will be determined.
2. Clients will be comfortable physically, and client and his family will have a healthy response to the pregnancy status of clients at high risk and complications are possible.
3. Clients and their families will understand the complications of pregnancy and complications that required treatment.
D. Implementation
1. Assessing the physiological status of the mother and fetus to determine early changes in the mother and fetus that require early intervention.
a. Perform continuous assessment during the intrapartum period.
b. Estimate the things that are unexpected and prepare a critical provision of nursing care if needed.
c. Document accurately the problems that have been studied and subsequent nursing interventions and their effectiveness.
2. Providing physical and emotional support.
a. Observation of clients and families on an emotional response and ability to cope with discomfort and pain.
b. Give the action to give a sense of comfort.
c. Coordinate physical care clients with the emotional needs of clients and families. (Clients with intrapartum complications umumrya require intravenous fluids and various procedures and treatments such as electronic monitoring, central venous lines, medications, and catheter retention.)
d. Review and support the psychosocial and emotional needs of clients and their families, particularly in relation to the possibility of loss and grieving.
e. Encourage and support the coping mechanisms, including aspects of loss and grieving.
3. Provides client and family counseling.
a. Give status information to help clients eliminate anxiety.
b. Give anticipatory guidance to clients and partners.
E. Evaluation Results
1. Clients and fetus to maintain normal physiological status; any irregularities that arise are identified and corrected early.
2. Couples demonstrate greater support, reduce anxiety and fear, and increase the use of coping techniques.
3. Clients and their partners expressed understanding of pregnancy complications and procedures that need to be done.
A. Assessment
1. Health History
a. Get a description of symptoms that include awitan, duration, location and trigger factors or events. The main signs and symptoms may include:
(1) The fluid which emanates suddenly from the vagina
(2) Each lot of vaginal bleeding
(3) The presence of uterine contractions with or without abdominal pain
(4) Decrease in fetal movement
b. Dig a mother and a family history of whether there are risk factors for intrapartum complications.
(1) maternal risk factors include:
(A) age younger than 18 years
(B) History of preterm birth
(C) poor obstetric history
(D) Multiple Pregnancy
(E) Hidramnion
(F) Smoking
(G) Hygiene bad
(H) poor nutrition
(I) Employment
(2) family risk factors include:
(A) History of diabetes
(B) history of birth complications in other family members.
c. Assess the family response to pregnancy, delivery of high risk, and possible crisis situations.
d. Assess the emotional connection a mother, father, and families and the possibility of perinatal loss and grief.
2. Physical examination
a. Vital signs
(1) Measure the maternal blood pressure, pulse, and breathing in the event of leakage of fluid or vaginal bleeding to assess the existence of shock.
(2) Measure the temperature of the mother to identify whether there is infection.
(3) Monitor the fetal heart rate to determine the status of the fetus.
b. Inspection
(1) Inspection of the output characteristics of the vagina on the perineum. Observations of color, odor, consistency, and the number of output vagina.
(2) Observation of the size and shape of the uterus.
(3) Inspection is there any sign of abnormal placenta visually.
c. Palpation
(1) Monitor the activity of the uterus to determine the progress of labor.
(2) Evaluation of cervical readiness for labor or progress in labor. Do not perform vaginal examination if there is bleeding.
3. Laboratory tests and diagnostic examinations
a. Ultrasound is used to determine the status of the fetus, knowing the location of the placenta, and determine the volume of amniotic fluid.
b. Kleihauer-Betke test or blood test fetal cells used to determine whether blood cells are the mother or fetus.
The cells remained colorless mother with staining. Fetal cells into a purple-pink when stained.
c. Nitrazin test paper and the fencing is used to determine whether there is rupture of amniotic bag. Paper nitrazin change color to green-blue when there is amniotic fluid. On microscopic examination of fluid samples, a ferning pattern, resembling the ice on the window, looking at the glass object. This is characteristic of a high fluid estrogen.
d. Monitoring of electronic uterus would indicate the presence of uterine contractions.
e. A complete blood count will record the existence of anemia or infection.
B. Nursing diagnosis.
In addition to the specific diagnosis of complications, the following are common nursing diagnoses for client care intrapartum high risk:
1. Anxiety
2. Fear
3. Ineffective family coping: disturbance
4. Adaptive grief
5. Impaired self esteem
6. Spiritual distress
7. Knowledge deficit
8. Painful
9. Risk of injury
C. Planning and identification results
1. Threats to the result of physical and emotional end of pregnancy the optimal will be determined.
2. Clients will be comfortable physically, and client and his family will have a healthy response to the pregnancy status of clients at high risk and complications are possible.
3. Clients and their families will understand the complications of pregnancy and complications that required treatment.
D. Implementation
1. Assessing the physiological status of the mother and fetus to determine early changes in the mother and fetus that require early intervention.
a. Perform continuous assessment during the intrapartum period.
b. Estimate the things that are unexpected and prepare a critical provision of nursing care if needed.
c. Document accurately the problems that have been studied and subsequent nursing interventions and their effectiveness.
2. Providing physical and emotional support.
a. Observation of clients and families on an emotional response and ability to cope with discomfort and pain.
b. Give the action to give a sense of comfort.
c. Coordinate physical care clients with the emotional needs of clients and families. (Clients with intrapartum complications umumrya require intravenous fluids and various procedures and treatments such as electronic monitoring, central venous lines, medications, and catheter retention.)
d. Review and support the psychosocial and emotional needs of clients and their families, particularly in relation to the possibility of loss and grieving.
e. Encourage and support the coping mechanisms, including aspects of loss and grieving.
3. Provides client and family counseling.
a. Give status information to help clients eliminate anxiety.
b. Give anticipatory guidance to clients and partners.
E. Evaluation Results
1. Clients and fetus to maintain normal physiological status; any irregularities that arise are identified and corrected early.
2. Couples demonstrate greater support, reduce anxiety and fear, and increase the use of coping techniques.
3. Clients and their partners expressed understanding of pregnancy complications and procedures that need to be done.
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