The patient is a 34 week pregnant woman who presented with uterine cramping and fluid escape from the vagina. A positive ferns test indicated rupture of membranes, increasing risk of infection. The nurse will monitor the patient and fetus for 24-48 hours to assess for signs of infection or preterm labor. The nurse will educate the patient on infection symptoms and promote hand hygiene to prevent infection. The expected outcomes are the patient and fetus remain free of infection throughout the remainder of pregnancy.
The patient is a 34 week pregnant woman who presented with uterine cramping and fluid escape from the vagina. A positive ferns test indicated rupture of membranes, increasing risk of infection. The nurse will monitor the patient and fetus for 24-48 hours to assess for signs of infection or preterm labor. The nurse will educate the patient on infection symptoms and promote hand hygiene to prevent infection. The expected outcomes are the patient and fetus remain free of infection throughout the remainder of pregnancy.
The patient is a 34 week pregnant woman who presented with uterine cramping and fluid escape from the vagina. A positive ferns test indicated rupture of membranes, increasing risk of infection. The nurse will monitor the patient and fetus for 24-48 hours to assess for signs of infection or preterm labor. The nurse will educate the patient on infection symptoms and promote hand hygiene to prevent infection. The expected outcomes are the patient and fetus remain free of infection throughout the remainder of pregnancy.
CASE DIAGNOSIS SCIENTIFIC SHORT NURSING RATIONALE EXPECTED
RATIONALE TERM/LONG INTERVENTION OUTCOME
TERM S: Risk for infection The Fern Test, Short Term -The nurse will -Maternal and fetal -Pt will be free -34 wks AOG C/O related to loss of often used in -Evalulate client assess the patient infection is higher from any signs and with uterine protective barrier conjunction with for 24 to 48 hours from any signs and in client with symptoms of cramping and fluid as evidence by the Amnio Test or to monitor for symptoms of PROM and must infection such as escape in the positive ferns test. Nitrazine pH preterm labor and infection every 4 be treated quickly foul vagina. paper test, administration of hours while to avoid fetal smelling/looking detects leakage of antibiotics to hospitalized. compromise. vaginal drainage, amniotic fluid prevent infection. -Perform sterile -Vaginal exam elevated O: from the -Monitor Fetal speculum vaginal may be required to temperature, BP: 110/80 membranes Heart to ensure the exam confirm diagnosis, uterus tenderness PR: 78 surrounding the fetus is not having -The nurse will but avoid multiple or rigidness, RR: 22 fetus during any fetal distress. educate the patient digital vaginal diminished fetal T: 37.1 pregnancy. on 6 signs and exams to reduce movement, Cervical Dilation: Ruptured Long Term: symptoms of the risk of tachycardia, and 2cm membranes infection the infection. Reserve hypotension Effaced: 10% increase the risk of -Client will be free patient should these exams for throughout rest of FHT: 136/ min fetal infection and from infection. watch out for. when delivery is pregnancy (-) Cord subsequent -Monitor FHT -The nurse will imminent. .-The patient will Compression mortality. weekly. verbalize and -Client education verbalized 6 signs demonstrate on sign and and symptoms of proper hand symptoms infection to the hygiene infection will nurse. techniques to the allow a prompt -The patient will patient. intervention to verbalized the -The nurse will treat infection. importance of educate the patient -Using hand refraining from on the importance hygiene will sexual intercourse of refraining from prevent further of any type or any type of sexual introduction of usage of tampons intercourse and infection, as well until after tampons usage as refraining from pregnancy. until after sexual activity by pregnancy. client.