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 Q8HInderal 10mg 1 tab BIDMV (natalbes) tablet ODFC 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 PregnantBefore you get walking, learn some easy and sensible tips to make the most of your walk:

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 TipsStaying 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

NUTRITIONThe 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“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.”

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.

EXERCISE“hindi ako nag-eexercise pero

naglalakad naman ako paminsan- minsan”

“kadalasan nakaupo at nakahiga lang ako dito.”

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 20-

30 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.

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.

HYGIENE“dalawang beses sa isang araw akong

maligo.”“3 beses

magtoothbrush”“lagi kong

pinananatiling malinis katawan ko.”

“ngayon lang lit ako nakaligo, puro

pagpupunas lang dati.”“tatlong beses pa rin ako

nagsisiplyo.”

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.

SUBSTANCE USE“wala akong bsyo,

masama para sa baby ko.”

“wala akong bisyo” 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

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.

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.”

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 Normal Findings Actual Findings AnalysisGeneral Appearance Varies with lifestyle

Relaxed, erect posture, coordinated movement

Clean. NeatNo body odor

Healthy appearance

-the client wears a clean clothes, sitting on bed-conscious, coherent

- no body odor

NORMAL

Temperature 37 ۫ C (98.6 F) 37 ۫ C NORMALPulse Rate 80 bpm (60-100 bpm) 82 bpm NORMAL

Respiratory Rate 16 bpm (12 -20 bpm) 20 bpm NORMAL

Posture Erect posture and an active purposeful stride

suggest a feeling of well- being.

-Sits in erect posture-active

NORMAL

Mental Status:Verbal Behavior -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.

-the patient was able to answer well

-has an organized thoughts-she is cooperative

NORMAL

Hair -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

-black color of hair-her hair is evenly

distributed-smooth in texture

NORMAL

Skin -color varies from light to deep brown

-no edema, abrasions, pallor, cyanosis and lesions-moisture in skin folds and

axillae-good skin turgor

Color: slightly dark skinFeel: 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-

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

Immunology Result Unit Reference-ranges

Analysis?

FT3 (ECLIA) 3.710 Pmol/L 2.80-7.10FT4(ECLIA) 13.59 Pmol/L 12-22TSH(ECLIA) 2.370 uIU/ml 0.27-4.20

Urinalysis Result 07/21/08

Macroscopic exam

result Norm

Color straw Straw, amberTransparency S.I turbid clear

Reaction Acidic AcidicSpecific gravity 1.005 1.005-1.025

Sugar Negative NegativeProtein Negative Negative

Microscpic examRBC 0-2 0-1hpf

Pus Cell 0-2 0-2/hpfSquamous

Ephitilial cellsfew

Hematology 04/30/08

Pt Value Reference rangeLeukocyte count 9.8 x10 9/L 4.5-11.0Leukocyte diff.

countNeutrophils 0.67 0.35-0.65

Eosinophils 0.03 0.00-0.05Lymphocytes 0.30 0.20-0.40

Hemoglobin 110g/l 120-160hematocrit 0.36 vol. frac 0.37-0.41

Ultrasound 1Obstetrics Ultrasound Report

24 July 2008

Second and third trimester ultrasound report

Final impression:Cephalic presentation, live singleton

No previaPosterior placenta location]

Amniotic fluid volume: oligohydramnios (AFI=1.7cm)Placental grade: grade 1

Pregnancy Uterine, 21 wks 3 days AOG by fetal biometryIntramural myoma nodule, upper anterior (3.5 x 2.0)

With note of multicystic left kidneySuggest congental anomaly scan at 24 weeks AOG.

Ultrasound 2Obstetrics Ultrasound Report

7/28/2008

2nd and 3rd trimesterNumber of fetus: 1

Presentation: breechAmniotic fluid volume: 39 (2vp)

Q1- 1.8Q2- 2.1

Placenta location: fundus

Fetal BiometryBPD - 52mm 21weeks 4daysHC - 192mm 21weeks 3daysAC - 163mm 21weeks 1dayFL - 35mm 22weeks 1dayAV Sonar age 21 weeks 4 days

Estimated date of delivery: 12/04Wstimated fetal weight. 429 grams

Remarks: The amniotic Fluid index has improved slightly., but generally scanning showed still with oligohydramnios

Generic Name

Dosage/Frequency

Classification

Indications Contraindications

Side effects Nursing Considerati

ons

Cues Nursing Diagnosis

Analysis Planning Intervention Rationale Evaluation

O- Transabdominal Ultrasound resulting in

Oligohydramnios

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 environmen

tal 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

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

1. Assess clients ability to

understand teaching

2. Provide a comfortable

quite setting for teaching and

invite family to

1. Assessment provide info to

guide planning an individualized

teaching program to ensure the

clients understanding

2. Intervention decrease

distraction and promote learning;

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

understanding of individual

factors that contribute to possibility of fetal injury and take steps to

correct her situation

3. Abide to the doctors order and health teachings.

participate

3. Provide written

information on oligohydramnios about its causes,

effect and complication

4. Provide information on importance of

increasing fluid intake

5. Instruct the client to increase

fluid intake

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 awareness regarding

importance of increasing fluid

intake

5. Studies show that oral hydration, by having the women

drink 2 liters of water, increases the

AFI by 30%.

Cues Nursing Diagnosis

Analysis Planning Intervention Rationale Evaluation

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,gumagalaw lang yung baby sa tiyan ko” as

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)

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

labor2.

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

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

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

understanding about s/s of preterm labor and what’s its

possible prevention

stated by the client

O- less anxiety

participate in session

3. Assist clients understanding of

the risks of preterm labor

and birth for her baby.

4. Help client to identify Braxton-

Hicks contractions she

may be experiencing : If

she says she doesn’t have any, ask her if yje baby ever “balls up” and

explain that this is a contraction

5. Teach client to palpate Braxton-

Hicks contractions at

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 mild uterine

contraction. Many women are

unaware that Braxton-Hicks are contraction even if

they are not painful

5. Teaching promotes self care and assessment skills. The fundus

is the thickest part

the fundus, moving fingertips around. Teach to time frequency of contractions

from the start of one contraction to the beginning

of the next. Praise effort

6. Teach client to lie down on her left side 2 or 3

times a day and palpate for

contractions noting fetal

movement(“kick counts”) and to

keep a journal of findings

7. Teach other s/s of preterm labor to report: dull low back pain, pelvic pressure, abdominal

cramping without diarrhea or an

increase in

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.

vaginal discharge

especially if watery or bloody.

8. Instruct client to drink a glass of water or juice every hour or 2-3 quarts/day and to void at least every 2h while

awake

9. Instruct client to avoid nipple stimulation and possibly avoid

sexual intercourse or to use condoms as

advised by caregiver

10. Instruct client that if she feels

an unusual contractions to

drink large amount of water and lie down on

8. Dehydration or a distended bladder may

increase uterine irritability/activity.

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

her left side. If pattern

continues for 20-30 minutes or becomes more intense to call the physician

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:

3. 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

understanding about s/s of preterm labor and what’s its

possible prevention

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

comply.

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 Rank JustificationRisk for Fetal Injury

related to cord compression secondary to decreased amniotic fluid as manifested bu

Trans abdominal ultrasound result.

1 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.

Hostst

Agent

EnvironmentEnvironmentnt

ECOLOGIC MODEL

A. HypothesisBased 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

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

be present or absent for an illness to occur. In this case, the agent will be the mother, Second, the host which is the fetus, a 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 awayfrom 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