Group Members: NCMA219 RLE

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

- Castro, Myca LABORATORY COURSE TASKJonalyn
- Salvador, 3
- Marin, Hilary BSN 2-YB-16
- Tanael, Ma. Crisheil Jem
Hypothetical Subjective Risk for disturbed Within 1 to 2 hours
- Reformina, Shannel Maeof 1. Review history of 1.  To identify possible After rendering all t
Data: maternal-fetal dyad rendering nursing labor, onset, and duration. causes, needed diagnostic necessary nursing
- “Sobrang sakit na po, related to shoulder intervention, the patient studies, and appropriate interventions, the pa
Doc hindi ko na po dystocia as manifested will be able to: interventions. was able to:
kaya hindi na rin po by gestational diabetes
1. Manifest and maintain 2. Monitor for signs of 2. Development of amnionitis 1. Maintain a fluid bal
ako komportable” as at 28 weeks age of
fluid balance, as will be amnionitis. Note the is related to length of labor, so as evidenced by moist
verbalized by the gestation and
evidenced by moist mucous cervix condition, elevated that delivery should occur mucous membranes an
patient. spontaneous rupture of
membranes, and appropriate temperature or odor, and within 24 hr after rupture of appropriate urine outp
membrane at 3cm.
Objective Data: urine output. color of vaginal membranes. A rigid cervix
- AOG: 41 weeks discharge. will not dilate, impending
- Cervix: 3cm dilated 2. Prevent from suffering fetal descent/labor progress. 2. Prevent further
to further possible complications.
upon internal 3. Evaluate the current
examination, 7cm complications. 3. Excess maternal exhaustion
level of fatigue, as well as
after 4 hours, 10cm contributes to secondary
3. Improve labor pattern activity and rest prior to 3. Improve labor patte
after internal dysfunction, or may be the
and reduce identified risk onset of labor. and reduced the identi
examination result of prolonged labor/false
factors. risk factors.
- Fundic Height: labor.
40cm 4. Note for effacement, 4. Handle and manage
4. Handle and manage any 4. These indicators of labor
- The head had fetal station, and fetal distress.
indicators of fetal distress. progress may identify a
crowned in a presentation.
contributing cause of 5. Have normal FHR l
occipito-anterior 5. Display FHR within prolonged labor
position normal limits, with good 5. Review bowel habits good variability, and n
- Notices that the variability, and no late and regularity of deceleration noted.
5. Bowel fullness may hinder
head did not extend deceleration. evacuation. uterine activity and interfere
normally on the with the fetal descent. 6. Prevent severe vagi
perineum 6. Prevent severity chances 6. Assess for bladder
tears and bladder injur
- The chin appeared of vaginal tears and bladder fullness over symphysis 6. A full bladder may inhibit
to be fixed in the injury. pubis. uterine activity and interfere
perineum with the fetal descent. 7. Feel less fatigue.
- Patient attempted 7. Lessen current level of 7. Place client in lateral
to deliver the fatigue. recumbent position. 7. Relaxation may correct a
shoulders after 3 hypertonic pattern. 8. Be freed from suffe
8. Be free from possible Ambulation may assist
contractions but not
further sufferings. gravitational forces in Goal met.
achieved.
- Normal Pelvic stimulating normal labor
Ultrasound 8. Note sign of fetal pattern and cervical dilation.
- Fetal movement is distress, cessation of
8. To monitor indication of
actively normal. contractions, presence of
developing uterine tear or
vaginal bleeding. acute rupture necessitating
emergency surgery.
9. Prepare client for
amniotomy assist with the 9. Active management of
procedure when cervix is labor protocols may support
3-4 cm dilated. amniotomy once presenting
part is engaged to accelerate
labor/help prevent dystocia.
10. Assess for
malpositioning using 10. To help assess the fetus’
Leopold’s maneuvers and current position and
findings on internal determine fetal distress.
examination (location of
fontanelles and cranial
sutures).

11. Note for the color and

11. To assess the stage of the
amount of amniotic fluid
membrane rupture.
when bag of water
rupture.

12. Assess FHR manually 12. To identify if there’s a

or electronically. Note possible fetal distress.
variability, periodic
changes, and baseline
rate.

13. Prepare for delivery in 13. This is an alternative

posterior position. delivery technique for
Alternatively, apply dystocia.
vacuum extractor as
indicated.

14. This is an alternative way

14. Prepare for cesarean to deliver the fetus to avoid
delivery if fetus fails to further maternal-fetal
descend. complications.