Ncp - Perinatal Finals

8/3/2019 Ncp - Perinatal Finals

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Name : Janette L. Ortega, RMT,RN.

FINAL EXAMINATION IN PERSPECTIVE OF PERINATAL NURSING

1st Semester (SY 2011-2012)

Case #1

Data/Cues Nursing DiagnosisOutcome

ManifestationsPlanning Intervention Rationale Ev

Subjective:“I’m running tothe bathroom tourinate, It seemslike all the time.As verbalized by thepatient.

Knowledge deficient

regarding pregnancycondition r/t lack of information.

Risk for NutritionalImbalanced: less thanbody requirements r/tDifficulty in eatingsecondary to nausea

Client will gain enough

knowledge regardingpregnancy and its effectson her body. After consultation.

Few days after consultation, client will beable to demonstratemaintenance of desiredweight during pregnancyand experience no signsof malnutrition.

Client will verbalize

understanding of her condition.

Client will verbalizeless difficulty inconsuming food.

Independent:Observe client’s ability

and readiness to learn.Explain to the patientthat what she isexperiencing is normalduring pregnancy.Explanation must bedone in a manner thatcan be easilyunderstood. As muchas possible, alsoinvolve patient’ssignificant other or close relative duringhealth education.

Provide for feedingsafety by advisingclient to avoid eating inlying down position.

Advise client to dividefeedings into smallamounts and consumeit frequently.

This is done to further

determine the client’scapacity to learn and toeasily understand her state of health.

This reduces risk for aspiration andregurgitation.

This enhances digestionand can improve client’sappetite.

Patient ve

understanshe is exnormal dpregnancmet.

Goal metverbalizein eating maintaineweight wimalnutrit



Case #1



Nausea r/t pregnancy Few days after consultation, client will be

able to report decreasednausea.

Client will identify andavoid foods that can

aggravate nausea andbe able to identifyfactors that will lessennausea.

Weigh, as indicated

Instruct client to avoidcold & hot liquids,

caffeine & spicy food.Advise her to eliminateUnpleasant sights andodors from the eatingarea.

Evaluates effectivenessor need for changes innutritional therapy.

Pregnant women haveincreased sensitivity to

their surroundingsespecially with what theysmell or see.Eliminating such foodfrom the diet andavoiding unpleasantodors at the eating areawill decrease nausea.

Goal metable to id

avoid naufoods anddecrease

Case #2





Subjective:Client states concernabout ability to cope withpain.

Objective:

• Inwardly focused

• Apprehensive

• Increaseddependency

• Limited ability tofollow directions

Altered AuditorySensory Perception r/tphysiological stressfrom labor and delivery

Fear r/t unpredictabilityof uterine contractions

Anxiety r/t lack of knowledge of relaxation & breathingexercises secondary togiving birth to firstchild.

Client will demonstrateunderstanding of copingmechanism during labor by being morecooperative.

Client will verbalize andrelate an increase inpsychological andphysiological comfort.

Client will be able tounderstand her situation and be ableto cooperate withhealth team providers.

Client will show adecrease in anxiety,manifesting anincreasepsychological andphysiological comfort.

Independent:Encourage goodcommunication byspeaking distinctly andfacing the client whenspeaking with her.

Provide an emotionallynon-threateningbirthing atmosphere.Teach relaxationtechniques such asslow, rhythmicbreathing andprogressive relaxationof the muscle groups.

Use simple, direct andunderstandablestatements.

Limit excess light andnoise.

Good communicationincreases the chances of good outcomes andincreases client’s moraleand satisfaction with her medical care.

To facilitate client’scooperation and further decrease anxiety.

Direct and simplestatements help preventconfusion and client’shelp to relax.Limiting visual & auditorystressors will be able todecrease client’s anxiety.

Partially gsomehowcooperathealthcawithout hClient waable to fogiven to hhealthca

Goal metable to shanxiety.



Case #3



Subjective:

• Pain scale –7/10

• Difficulty breastfeeding

• Client states

that she hasn’tvoided yet.

• Emotionalstatus isdistressed

Risk for uterineinfection r/t bacterialinvasion secondary tolochial discharge andtrauma(episiotomy)

Client verbalizesunderstanding of the riskfactors, and achievestimely wound healing.

After several days of nursing intervention,client will report riskfactors associatedwith infection and be

able to identifyprecautions needed.Client will continue tobe free from anysymptoms of infectionduring postpartumperiod.

Independent:Vital signs, lochia(character,amount,odor and presence of clots),fundal height andstatus of episiotomy

were monitored.

Proper perineal care &hygiene were enforced

Emphasized earlyambulation andbeginning postpartum

Exercises withresumption of normalactivities as tolerated.

Alterations from normalmay be signs of infection,retained fragments or sun involution of theuterus.

Appropriate self care of the perineum inpostpartum clientsreduce the risk of bacterial invasion. Cleanwarm water andantiseptic feminine washMaybe used.

NSD mothers areallowed to ambulate 4-8hrs after childbirth.

Circulation of blood ispromoted through regular movements and it helpsin the healing process;prevents constipation,circulatory problems andurinary problems;promote rapid recovery;hastens drainage of lochia; improves urinary& GI function; & providea sense of well-being.

Goal metredness odischargeepisiotomdischarge

odor; tem>40 C



Case #3



Objective:

• Client seemsmore focusedon her ownneeds, not on

her baby.• Bowels have

not moved,passing flatus

• Breasts are softwith colostrumsleaking; nipplecracked.

• Moderate lochia

Acute pain r/t tissuetrauma to perineumduring labor anddelivery, hemorrhoids,

engorged breasts andinvolution of uterus.

Client will report painrelief and will appear relaxed, able to sleep andrest.

Within a few daysafter nursinginterventions areapplied, client will

report decrease inpain.

Encouraged to eatfoods that are rich inprotein and Vitamin C.

Dependent:Intake of antibacterialMedications such ascephalexin &amoxicillin as per doctor’s order andadvice.

Independent:Evaluate pain regularlynoting characteristics,location and intensity.

Emphasized client’sresponsibility for reporting pain/relief of pain completely.Assess client’s vitalsigns, notingtachycardia,hypertension andincreased respirationeven if client deniespain

Vit.C is known to preventinfection; Protein isneeded for tissue repair & regeneration; meatproducts, nuts and

legumes are rich sourcesof protein.

Antibiotics are used totreat and preventinfections caused bysusceptible pathogens inskin structure infections.

Provides informationabout need for effectiveness of

interventions.

Changes in these vitalsigns often indicate acutepain and discomfort.Some clients may have aslightly lower BP whichreturns to normal rangeafter pain relief isachieved.

Goal metverbalizeusing pai

pain scaleClient wawell and than befo.



Case #3



Encourage use of relaxation techniques

Collaborative:Administer medicationsas indicated:

• NSAIDs

• Analgesics IV

Improves circulation,reduces muscle tensionand anxiety associatedwith pain.

Use for mild to moderatepainAnalgesics given IVreach the pin centersimmediately, providingmore effective relief.

.

Ncp - Perinatal Finals

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