University:
Lincoln University
Course:
NUR301 | Fundamental of Nursing
Academic year:

2024
Views:

162

Pages:

3
Author:

Bobby E.

Intranatal Nursing Care : Stage 2 Assessment - Activity/rest Reported fatigue, reported inability to perform self-motivation/relaxation techniques and presence of dark circles under the eyes - Circulation Blood pressure increases by 5-10 mmHg - Ego integrity Client feels loss of control/conversely - Elimination Desire to defecate, possible bladder distension - Pain/discomfort May be characterized by moaning/crying during contractions, reporting a burning/stretching feeling in the perineum, Legs may tremble during propulsive efforts and Strong uterine contractions occur 1.5 – 2 minutes - Respiration Increased respiratory frequency - Sexuality Full dilatation of the cervix (10 cm), increased vaginal bleeding, membranes may rupture, if intact and increased amniotic fluid discharge during contractions. Nursing Diagnosis and Nursing Plan 1) Remaining fluid volume deficiency related to active loss, decreased intake Objective: - There is no lack of fluid volume in the body with KH: - Vital signs are within normal limits. - Urine output is adequate. - Thick mucous membrane. - Free from thirst. Intervention: a) Measure input and output. b) Assess skin turgor, give oral fluids. c) Monitor vital signs as indicated. d) Review DJJ and pay attention to periodic changes. e) Position the client upright or laterally. f) Collaborative administration of parenteral fluids. 2) Maternal infection risk related to repeated invasive procedures. Tissue trauma, prolonged labor. Objective: The client does not experience infection with KH: Free from signs of infection (rubor, tumor, dolor, calor, and functionallaesa) Intervention: a) Perform perineal care every 4 hours using aseptic technique. b) Note the date and time of rupture of membranes. c) Perform vaginal examinations only if absolutely necessary using aseptic technique. d) Monitor vital signs and leukocyte laboratories. e) Use surgical aseptics in equipment preparation. f) Limit the number of people present at the time of delivery. 3) High risk of damage to skin integrity related to hypertonic interaction patterns Intervention: a) Help the client and partner get into the right position b) Help clients as needed c) Collaboration of midline or medio lateral episiotomy d) Collaboration on bladder monitoring and catheterization