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  • NCP Cord Prolapse Frias Ea Lissandra C

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    Fatima Medriza Duran
    87 views2 pages
    This nursing care plan addresses a client experiencing cord prolapse. The assessment notes the client's vital signs and that the baby's cord is prolapsed. The nursing diagnosis is risk for injury and infection to the mother and fetus related to cord prolapse. The plan is to monitor vital signs, assess for infection signs, maintain normal fetal heart rate and the client's condition, provide health education, and treat dehydration with IV fluids and medications. The goal is for the client and fetus to be free from infection and injury.

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    This nursing care plan addresses a client experiencing cord prolapse. The assessment notes the client's vital signs and that the baby's cord is prolapsed. The nursing diagnosis is risk for injury and infection to the mother and fetus related to cord prolapse. The plan is to monitor vital signs, assess for infection signs, maintain normal fetal heart rate and the client's condition, provide health education, and treat dehydration with IV fluids and medications. The goal is for the client and fetus to be free from infection and injury.

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    © All Rights Reserved
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    87 views2 pages

    NCP Cord Prolapse Frias Ea Lissandra C

    Uploaded by

    Fatima Medriza Duran
    This nursing care plan addresses a client experiencing cord prolapse. The assessment notes the client's vital signs and that the baby's cord is prolapsed. The nursing diagnosis is risk for injury and infection to the mother and fetus related to cord prolapse. The plan is to monitor vital signs, assess for infection signs, maintain normal fetal heart rate and the client's condition, provide health education, and treat dehydration with IV fluids and medications. The goal is for the client and fetus to be free from infection and injury.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 2

    Frias, Ea Lissandra C.

    Nursing Care Plan 2BSN-4

    Assessment Nursing Nursing Analysis Planning Intervention Rationale Evaluation


    Diagnosis
    Subjective: Independent:
    Risk for injury Amniotic sac After 30 Monitor the vital The incidence of infection After 30 minutes of
    Objective: and infection allows the fetus to minutes of signs of the patient. after rupture of membrane, as intervention:
     Bp: 150/100 of the mother move freely within intervention, evidence of abnormal Vital
     Pulse: 78bpm and fetus walls of the uterus. the client will signs.
     Respiration: related to cord It serves as a be able to: Client’s vital sign
    22/min prolapsed as cushion for the Assess signs of Identified signs of infection and condition is
     Temperature: manifested by growing fetus but Maintain vital infection or injury; assist in determining the within normal
    36.9 degrees early rupture also serves to sign and if present, notify mode of treatment and may range.
     Weight: 158 of membrane. facilitate the condition health care provider reduce risk of super-infection
    lbs. exchange of within normal as soon as possible that may Client’s fetal heart
     FHT:115bpm nutrients, water, range. risk lives for both of the natal rate is within
     Cord of the biochemical and mother. normal ranger.
    baby is products between Maintain
    prolapsed” mother and fetus. normal range Assess the well- To assess fetal well-being Client verbalized
    of fetal heart being of the fetus and identify any changes that risk factors
    rate. (Fetal Heart Rate) might be associated with associated with
    problems during pregnancy cord prolapsed.
    Verbalize risk or labor.
    Once the factors Client is free from
    membranes rupture, associated Give health Understanding symptoms of infection and injury
    the barrier with cord education on the infection may help the (fetal and mother)
    protecting the baby prolapsed. risk factors as well mother to be aware of herself
    from bacteria is no as the signs and and to reduce risk of
    longer in place. Be free from symptoms of acquiring infective agents.
    This means the infection and infection.
    mother and the injury (fetal
    baby are not so and mother) Change maternal To relieve the pressure of the
    well protected from position, usually in presenting part so that the
    potential infections knee-chest position. oxygen can get through the
    baby.

    Insert catheter and Since transfer to hospital has


    fill the urinary been ordered by the
    bladder of 500- physician, elevation though
    Prolapsed umbilical 700ml IVF. bladder filling may be more
    cord occurs when the practical.
    baby’s umbilical

    This study source was downloaded by 100000843007228 from CourseHero.com on 03-06-2022 04:19:15 GMT -06:00
    cord falls into the Elevate presenting To relieve pressure on
    birth canal ahead of the part by inserting umbilical cord and prevent
    baby’s head or other fingers into vagina mechanical vascular
    parts of the baby’s and push the fetus’ occlusion.
    body head upward

    Dependent:
    When the cord
    become’s Insert and IVF of To treat dehydration and to
    compressed, the D5% Lactated restore fluid balance after
    fetus's oxygen and Ringer’s 1 liter to significant blood loss.
    blood supply is run for 20 gtts/min
    deminished or cut
    off. This can lead Administer Cefuroxime is used to treat
    to neonatal cefuroxime 1 gm certain infections caused by
    hypoxia, hypoxic- IV ANST & bacteria and Hydralazine, is a
    ischemic Hydralazine 5mg medication used to treat high
    encephalopathy IV blood pressure and heart
    (HIE), and failure. This includes high
    brain injury. blood pressure in pregnancy
    and very high blood pressure
    resulting in symptoms.

    Collaborative:
    Therefore, risk of Transfer to hospital To provide more advanced
    infection and injury of choice for health care and comfort to
    may occur. Emergency co- the patient
    management

    This study source was downloaded by 100000843007228 from CourseHero.com on 03-06-2022 04:19:15 GMT -06:00
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