NURSING PROCESS PAPER/ PLAN OF CARE

NURSING PROCESS PAPER/ PLAN OF CARE Year 1 (Nursing 11/12) Student Name: Admission Date: Date of Care: 04/02/2020 Medical Diagnosis(es): Preecalmpsia, Induction of Labor Past Medical History: __N/A, 36_weeks 3 days gestation Allergies/Reaction: NKA Patient Height: 163 cm Patient Weight: 81.6 kg Developmental Stage/Resolution: 29yo Intimacy vs Isolation: Accompanied by husband______________ PATHOPHYSIOLOGY (Please analyze your patient’s pathophysiology (must be cited from your textbook) and any comorbidities and discuss the impact on the patient’s ADL’s) Pathophysiology, Comorbidities, Impact on ADLs: Stages of Labor: Stage 1: Cervical dilation, ROM, lasts about 12 hours primigravida, about 6 hours multigravida, visceral pain of diffuse abdominal cramping and uterine contraction due to dilation and distension of cervix and lower uterine segment. Latent Phase: Cervical effacement 0-40%, dilation 0-3 cm, contractions every 5-10 min lasting 30-45 sec, mild intensity. Lasts about 9 hours for nulliparous women, about 6 hours for multiparous women, with wide variations for both. Patient may be very talkative, apprehensive, but excited. Active Phase: Effacement 40-80%, dilation 4-7 cm at 1.2 cm/hr for nulliparous women, 1.5 cm/hr for multiparous. Contractions every 2-5 min lasting 45-60 seconds, moderate to strong intensity. Up to 6 hours in nulliparous women, up to 4.5 hours in multiparous women. Patient becomes more intense and inwardly focused. Transition Phase: effacement 80-100%, dilation 8- 10 cm. . Fetal descent about 1cm/hr in nulliparous women, 2 cm/hr in multiparous women. Contractions every 1-2 min lasting 60-90 seconds; strong, hard, painful intensity . Lasts about 1 hour in nulliparous women, about 15-30 minutes in multiparous women. Great pressure in rectum, strong desire to contract abdominal muscles and bear down. Patient may experience nausea, vomiting, trembling extremities, bachache, restless movement, increased bloody show from vagina, inability to relax, diaphoresis, increased apprehension and irritability, feelings of loss of control and being overwhelmed. Stage 2: Expulsive Stage. Contractions every 2-3 minutes, lasting 60-90 seconds, strong in intensity. About 1 hour in nulliparous women, and about 30 min in multiparous women. Maternal urge to push. Patient feels more in control, less irritable and agitated, and is focused on pushing. Pelvic Phase: Fetal head negotiating pelvis, rotating, and advancing in descent Perineal Phase/Active Pushing: Strong urge to push as fetal head is lowered, distending perineum, bulges, increase in bloody show, fetal head becomes apparent at vaginal opening, disappears between contractions. Crowning, rotation. Lasts up to 3 hours in first labor, up to hour in subsequent ones. Stage 3: Begins with birth of newborn, ends with separation and birth of placenta. Placental Separation: Contractions cause uterus to pull away from uterine wall. Uterus rises upward, umbilical cord lengthens, blood released from vaginal opening, uterus changes to globular shape. Placental Expulsion: Continued contractions cause placenta to be expelled. Stage 4: Initiation of postpartum period, 1- 4 hours after birth. Patient usually feels sense of peace and excitement. Patient is wide awake, and very talkative initially. Attachment process begins and patient may begin inspecting newborn and express desire to cuddle and breast-feed. Lochia is red, mixed with small clothes, and of moderate flow. Fundus should be firm, typically midline between umbilicus and symphysis, slowly rising to level of umbilicus during 1st hour. Patient may be thirsty and hungry. Bladder is usually hypotonic. Cramp-like discomfort expected. – Ricci Pg 474-482. Cardiorespiratory Adaptations of Fetus: Ultrafiltrate of amniotic fluid removed from lungs with compression of thorax during passage through birth canal. Detachmentof placenta eliminates blood reservoir. Hypercapnia, hypoxia, acidosis resulting from normal labor initiates respirations. First breath of life increases transpulmonary pressure, results in diaphragmatic descent. Respiration causes oxygen pressure in lungs. Surfactant aids in expansion of lungs, allows for increase in tidal volume. Decrease in pulmonary vascular resistance, increased pulmonary blood flow, increased pressure in left atrium, decreased pressure in right atrium, closure of foramen ovale within minutes after birth, increased oxygen levels increase systemic vascular resistance, decreased vena cava return reduces blood flow in umbilical vein. Ductus venosus causes increased pressure in aorta, forcing closure of ductus arteriosus within 10-15 hours. Increased catecholamines stimulate increased cardiac output/contractility, surfactant release, promotion of pulmonary fluid clearance. – Ricci Pg 600-605 Comorbidities Patient is diagnosed with severe preecalmpsia, resulting from a number of widespread pathologic changes that can cause pulmonary edema, oliguria, seizures, thrombocytopenia, and abnormal liver enzymes. Widespread vasospasms (condition in which arterial vessels spasm, leading to vasoconstriction) and endothelial injury leads to platelet adherence, fibrin deposition, and schistocyte (erythrocyte fragments). This This study source was downloaded by from CourseH on :03:14 GMT -05:00