FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING
BATCH 2010

CASE PRESENTATION
BSN048
GROUP 190-B
Rieza, Wendy Ann M.
Salamat, Neoma Syrilla T.
Santos, Janessa Joy S.

Prof. Jeannie Patrimonio

 Introduction:

The client chosen for this case is R.T.C NORD, female, 26 years of age,. Her religion is Roman Catholic She was
born on July 24, 1981 in Tuguegarao City. And married to PO1 T.C PNPSAF B96L28 from Paliparan Dasma, Cavite.
Admitted to OBward by admitting officer/ admitting physician PSUPT Guiatani on 21 2330H July 2008, room
number 3 with hospital no. 04-01-35. Is Dependent, ambulatory, First type of admission with Direct source of
Admission. Has admitting Diagnosis of G2P1 PU 23 4/7 weeks AOG, Pre Term Labor. R.T.C is accompanied by husband
with cc of vaginal spotting or verbalized. LmP is February 22, 2008, EDC is November 29, 2008, RR of 21 cycles/min,
BP 130/80mmhg with temp of 36.7 and cardiac rate of 78bpm.Conscious and coherent, with negative uterine
contraction and positive on vaginal spotting.
We chose this case because this case is more challenging among other cases that we’ve handled and there’s
a lot to learn from this case. In addition to that, the diagnosis of the patient might be a threat to the fetus that needs
to be focused on, assessed for nursing intervention to help prevent further complications.

II Nursing History
A. Past health History
R.T.C 26 y/o G2P1 doesn’t have history on Hypertension, Diabetes mellitus, and asthma. She is diagnosed of
hyperthyroidism during her first pregnancy on the year 2006 on PTV but stop after several weeks.

B. History of Present Illness

 R.T.C was admitted dependent, ambulatory, PU 23 4/7 weeks of AOG, Pre Term Labor. Consulted regarding
thyroid problem, still for follow up of FT3 FT4 TSH. Undergone Transabdominal Ultrasound result revealed
oligohyramnios (AFI- 1.7cm).

Discharge Plan

Medication: Isoxsuprine tablet Q8H

Inderal 10mg 1 tab BID
MV (natalbes) tablet OD
FC Fumirate tab (fumuim) OD

Exercise:
-CBR

Treatment:
-rest and sleep
-medication
-increase fluid intake

Health Teaching:

Low levels of amniotic fluid can increase your risk of complications during labor. The main concern is that the fluid level will get so
low that your baby's movements or your contractions will compress the umbilical cord. So Oligohydramnios can sometimes be
treated with bed rest, oral and intravenous hydration, antibiotics, steroids, and amnioinfusion. It is advised to
continue the increse of oral fluids, have bed rest and consult doctor as advised.

Out Patient:
-The patient should consult doctor/physician if there are complications after discharge for immediate action.
-The patient should follow the physicians order.

Diet:

Practice good eating habits. Just as important as what you eat is the manner in which you eat. Eat moderate
proportions, eat at regular times and relax while you eat advised a low residue diet. Increase fluid intake to
2liters/day.

Maintain a healthy lifestyle

Walking during pregnancy is a great way to feel good and become more fit.

Best Walking Tips While Pregnant

Before you get walking, learn some easy and sensible tips to make the most of your walk:

 Stand tall. Stand up straight and use your abdominal muscles to support your back. Practice relaxing your
stomach, then pulling it back in so you get a feel for what it means to hold in your abs. If you're very
pregnant, you may want to wear a maternity belt under your clothes for additional abdominal support. A
maternity belt has is a wide band that goes under your tummy for support. You can buy one in a maternity
store or catalog.
 Look ahead. Look at the ground a few steps ahead of you — not straight down (which strains your neck and
hunches your shoulders) or far off into the distance (in case you have to dodge people or tackle tough
terrain).
 Get into position. Keep your elbows close to your body, your shoulders back slightly, and your elbows bent.
Hold your hands in light fists, as if you're grasping an egg.
 Start off small. Begin walking in short strides. Long ones can hurt your hips and pelvic area, which are
loosened by hormones released during pregnancy.

Safety:
Pregnancy Fitness Safety Tips
Staying fit during pregnancy is an important part of feeling your best. If yours is a low-risk pregnancy, and your
doctor approves, you can continue to exercise and derive health benefits even from mild-to-moderate fitness
routines. The American College of Obstetricians and Gynecologists recommends following these guidelines to ensure
a healthy pregnancy — for you and your baby.

• Stay consistent. Exercise regularly (at least three times a week) — not intermittently. Exercising three days
a week is a good routine. Keep your fitness regimen in the mild-to-moderate range.
• Easy does it. Avoid activities that require jumping motions or sudden changes in direction because these
may strain your joints and injure you.
• Watch your back. Don't exercise on your back after the first trimester. Also, avoid prolonged periods of
motionless standing. Both actions can reduce blood flow to the uterus.
• Don't overexert yourself. Be aware that you have less oxygen available for exercise. Stop exercising when
you become fatigued, and don't exercise to the point of exhaustion.
• Keep your balance. Avoid exercises that could cause a quick loss of balance or mild trauma to the abdomen.
• Eat a good diet. Be sure you eat an adequate diet that allows you to gain 25 to 35 pounds over the nine
months. Most pregnant women require an additional 300 calories a day. If you exercise regularly, you will
probably require more. Include plenty of carbohydrates in your diet, as pregnant women use up this fuel
source more quickly during exercise than non-pregnant women.
• Drink up! Drink plenty of water to keep you hydrated and prevent overheating.
• Get comfortable. Wear comfortable, cool, and supportive clothing in layers that can be easily removed.
Wear a bra that fits properly and supports your breasts.
• Keep cool. Be mindful not to become overheated, especially in the first trimester. According to the American
College of Obstetricians and Gynecologists, overheating, especially in the first trimester, may be a
contributing factor to the development of birth defects. Drink plenty of fluids before and during exercise, wear
layers of "breathable" clothing, don't exercise on hot, humid days, and don't immerse yourself in a hot tub or
sauna.
• Avoid certain sports. According to the Mayo Clinic, you'll want to avoid certain sports altogether while
you're pregnant. These include activities at high altitudes and those that are associated with a risk of falling or
colliding with another participant, such as horseback riding, climbing and snow and water skiing. Also, avoid
scuba diving because there's a risk that your oxygen intake could be compromised, and diving can put
pressure on your organs and baby.
 Anatomy and Physiology

Amniotic fluid is the nourishing and protecting liquid contained by the

amnion of a pregnant woman.

The amnion grows and begins to fill, mainly with water, around two
weeks after fertilization. After a further 10 weeks the liquid contains
proteins, carbohydrates, lipids and phospholipids, urea and electrolytes,
all which aid in the growth of the fetus. In the late stages of gestation
much of the amniotic fluid consists of fetal urine.

The amniotic fluid increases in volume as the fetus grows. The amount
of amniotic fluid is greatest at about 34 weeks after conception or 34
weeks ga (gestational age). At 34 weeks ga, the amount of amniotic
fluid is about 800 ml. This amount reduces to about 600 ml at 40 weeks
ga when the baby is born.

Amniotic fluid is continually being swallowed and "inhaled" and replaced through being "exhaled", as well as being
urinated by the baby. It is essential that the amniotic fluid be breathed into the lungs by the fetus in order for the
lungs to develop normally. Swallowed aminotic fluid contributes to the formation of meconium.
Analysis of amniotic fluid, drawn out of the mother's abdomen in an amniocentesis procedure, can reveal many
aspects of the baby's genetic health. This is because the fluid also contains fetal cells which can be examined for
genetic defects. Recent research by researchers led by Anthony Atala of Wake Forest University and a team from
Harvard University has found that amniotic fluid is also a plentiful source of non-embryonic stem cells. These cells
have demonstrated the ability to differentiate into a number of different cell-types, including brain, liver and bone.

Amniotic fluid also protects the developing baby by cushioning against blows to the mother's abdomen, allows for
easier fetal movement, promotes muscular/skeletal development, and helps protect the fetus from heat loss.

The forewaters are released when the amnion ruptures, commonly known as when a woman's "water breaks". When
this occurs during labor at term, it is known as "spontaneous rupture of membranes" (SROM). If the rupture
precedes labor at term, however, it is referred to as "premature rupture of membranes" (PROM). The majority of the
hindwaters remain inside the womb until the baby is born.

Complications related to amniotic fluid

Too little amniotic fluid (oligohydramnios) or too much (polyhydramnios or hydramnios) can be a cause or an
indicator of problems for the mother and baby. In both cases the majority of pregnancies proceed normally and the
baby is born healthy but this isn't always the case. Babies with too little amniotic fluid can develop contractures of
the limbs, clubbing of the feet and hands, and also develop a life threatening condition called hypoplastic lungs. If a
baby is born with hypoplastic lungs, which are small underdeveloped lungs, this condition is potentially fatal and the
baby can die shortly after birth.

On every prenatal visit, the obstetrician/gynaecologist should measure the patient's fundal height with a tape
measure. It is important that the fundal height be measured and properly recorded to insure proper fetal growth and
the increasing development of amniotic fluid. The obstetrician/gynaecologist should also routinely ultrasound the
patient—this procedure will also give an indication of proper fetal growth and amniotic fluid development.
Oligohydramnios can be caused by infection, kidney dysfunction or malformation (since much of the late amniotic
fluid volume is urine), procedures such as chorionic villus sampling (CVS), and preterm premature rupture of
membranes (PPROM).
Oligohydramnios can sometimes be treated with bed rest, oral and intravenous hydration, antibiotics, steroids, and
amnioinfusion.

Polyhydramnios is a predisposing risk factor for cord prolapse and is sometimes a side effect of a macrosomic
pregnancy. Hydramnios is associated with esophageal atresia. Amniotic fluid is primarily produced by the mother
until 16 weeks of gestation.

COLOR OF AMNIOTIC FLUID WITH CONTRAINDICATIONS GREEN - neco state YELLOW - hemolitic deisease BROWN -
infection

III. Activities of daily living

Activities of Daily Before During Hospitalization Analysis & Interpretation

Living Hospitalization
 The client verbalized: “ Minsan ayoko ng She doesn’t have any problems
NUTRITION “ Nakakain ko gusto binibigay nilang ulam regarding her nutritional intake. She
ko, lalo na mga gulay. kaya nagpapabili ako sa increased her oral fluid intake to
Madalas akong labas. Madalas sabaw, improve her condition being
kumain ng meat.” atay, karne, at gulay diagnosed with oligohydramnios.
“ Hindi ako pero hindi na ako
masyadong umiinom mayadong kumakai ng Nutrition is vital aspect of the
ng tubig dati, mga 1 isda ngayon kasi ayoko health of women at all ages and is
liter lang.” yung amoy.” particularly important during the
“ Madami akong uminom childbearing years because it
ng tubig ngayon kasi yun affects the health and development
ang inadvice sa’kin. Mas of the child. An adequate food
madami pa sa 2 liters intake consists of a balance of
naiinom ko sa isang essential nutrients: water,
araw.” carbohydrates, proteins, fats,
vitamins, and minerals. Nutrition
during pregnancy has implications
for both the mother and the fetus.
The mother’s nutrition before
pregnancy is also important for the
health of the fetus.
The usual recommendations for
adults are to drink 8-10 cups (1
cup=8oz=237 ml) of water per day,
or 30 ml/kg of body weight, with a
minimum of 6 cups (1500 ml) for
small individuals. Because the
pregnant woman’s blood volume is
expanding water and other fluids
should be increased. The pregnant
woman needs an additional daily 30
ml of water per kilogram of body
weight gained.
 “Nakakadalawang “Dalawang beses dn The patient’s bowel movement is
ELIMINATION beses akong dumumi akong dumumi ditto sa normal and there is an increase in
sa isang araw.” isang araw.” her urinary elimination but it is still
“Madalas ako umihi “Bawat oras, umiihi ako normal because there is an increase
kapag napaparami sa isang araw.” in her fluid intake.
inom ko,kadalasan ay
sampung beses o di Elimination of the waste products of
kaya 15.” digestion from the body is essential
to health. There is an increased
urine flow and volume as well as
bowel movement for pregnant
women because of their increased
fluid intake and nutritious foods
intake and the supplements they
needed.
“hindi ako nag- “kadalasan nakaupo at The client is not capable of rigid
EXERCISE eexercise pero nakahiga lang ako dito.” exercises because of her condition.
naglalakad naman ako She is only allowed to have a
paminsan- minsan” complete bed rest.

Exercise to stay regular like walking

three to four times per week for 20-
30 minutes is recommended.
Regular exercise is essential for
healthy functioning of major body
systems. The benefits of exercise
on these system follows:
Musculoskeletal- size, shape, tone
& strength of muscles are maintain
with mild exercise and increases
with strenuous exercises.
Cardiovascular- increase heart rate.
Respiratory- ventilation increases.
 Gastrointestinal- improves the
appetite and increase
gastrointestinal tract tone,
facilitating peristalsis.
Metabolic- elevates metabolic rate.
Urinary- promote efficient blood
flow, body excretes waste more
effectively.
Psychoneuologic- produce a sense
of well-being and improes tolerance
to stress.
“dalawang beses sa “ngayon lang lit ako The patient was not allowed to take
HYGIENE isang araw akong nakaligo, puro a bath before that’s why she didn’t
maligo.” pagpupunas lang dati.” meet the standards regarding her
“3 beses “tatlong beses pa rin ako hygiene particularly in taking a
magtoothbrush” nagsisiplyo.” bath.
“lagi kong
pinananatiling malinis
katawan ko.”
“wala akong bsyo, “wala akong bisyo” The patient doesn’t take any drugs
SUBSTANCE USE masama para sa baby or substances that may affect her
ko.” health and the fetus inside her.

Women who are pregnant should

abstain from consuming alcohol.
Excessive, chronic ingestion of
alcohol can impair nutrition.
Excessive alcohol intake may limit
the necessary intake of calories and
nutrients. It may also affect the
health and development of the
growing fetus inside her womb.
Newborn born to mothers who
 smoke have lower birth weights, a
higher incidence of SIDS, a higher
incidence of premature birth and
are more likely to have episodes of
apnea.
Large doses of illicit drugs or street
drugs can cause low birth weight or
fetal distress.
“mga anim na oras “Minsan napuputol The client has an irregular sleeping
SLEEP & REST tulog ko dati.” pagtulog ko, pero pattern and does not meet the
“sa hapon kadalasan limang oras normal range of sleeping hours for
nagpapahinga din ako tulog ko.” pregnant women.
ng mga isang oras..”
Rest and Sleep are essential for
health. People who are ill frequently
require more rest and sleep than
usual same with those pregnant
women who needs more rest.

IV. Physical Assessment

Body Parts Normal Findings Actual Findings Analysis

General Appearance Varies with lifestyle -the client wears a clean NORMAL
Relaxed, erect posture, clothes, sitting on bed
coordinated movement -conscious, coherent
Clean. Neat - no body odor
No body odor
Healthy appearance
Temperature 37۫ C (98.6 F) 37۫ C NORMAL
Pulse Rate 80 bpm (60-100 bpm) 82 bpm NORMAL
Respiratory Rate 16 bpm (12 -20 bpm) 20 bpm NORMAL
 Posture Erect posture and an -Sits in erect posture NORMAL
active purposeful stride -active
suggest a feeling of well-
being.
Mental Status: -the patient was able to NORMAL
Verbal Behavior -Cooperative answer well
-Client’s response -has an organized thoughts
appropriate to situation -she is cooperative
-Quantity, quality and
organization of speech is
understandable, moderate
pace, exhibits thought
association
-thoughts are in logical
sequence, makes sense
and has sense of reality.
Hair -can be black, brown, or -black color of hair NORMAL
burgundy in color; free -her hair is evenly
from lice, nits and dandruff distributed
-maybe thick or thin; -smooth in texture
evenly distributed
-silky, resilient hair
-no infections or infestation
Skin -color varies from light to Color: slightly dark skin There is a presence of
deep brown Feel: warm to touch edema because of the IV
-no edema, abrasions, Turgor: good skin turgor insertions.
pallor, cyanosis and lesions -there is a presence of
-moisture in skin folds and edema
axillae
-good skin turgor
 V. Course in the Ward

R.T.C was admitted to Ob ward on July 21, 2008 with the BP of 130/80, temperature of 36.7’C and 23 4/7
weeks AOG. Diet is DAT. Undergone CBC and UA results were normal. Given IVF of D5 W 1L +8amps duvadilan to run
for 15ugtts/min after checking BP and CR. Given the medicine Ampicillin 1g IV q’6 ANST, Natalbes 1tab OD, Femiron
1tab OD, Folart (folic acid) 1 tab, calcium 1tab q’12. R.T.C undergone transvaginal ultrasound. Monitor V/S every
shift. 22 2100H July 2008. Continue duvadilan drip and increase OF 2L/day. Dx asymptomatic FT3 FT4 FST
(047/2008) normal. Undergone transabdominal ultrasound at 24 1500H July 2008 for amniotic fluis quantification
resulted oligohydramnios, intramural myoma nodule upper anterior (3.5x2.0cm) with note of multicystic left kidney,
suggested congenital anomaly scan at 24 weeks AOG by physician. Advised increase of Oral Fluids to 2L/day. 25
0700H July 2008, IVF to follow are D5LR 1L fast drip 300cc then regulate to 6 hrs, D5NM 1L X 6hours, D5LR IL X
6hours. To discontinue ampicillin IV and duvadillan drip to consume and then shift to duvadilan tablet BID. Advised to
maintain in lateral derubitus position. Monitored V/s FHT and recorded.1100H permitted to take a bath. Last Bp
taken was Immunology Result Unit Reference- Analysis?
ranges
110/70 FT3 (ECLIA) 3.710 Pmol/L 2.80-7.10
temperature is FT4(ECLIA) 13.59 Pmol/L 12-22
TSH(ECLIA) 2.370 uIU/ml 0.27-4.20
37’C RR-20, PR-
82. 26 0725H July 2008, R.T.C is advised on a low residue diet, still increase of fuid intake and to continue IV series
D5LR5 1L x 6 hours, D5NM 1L x 6 hours, D5NR IL x 6 hours, D5NM IL x 6 hours, pt may turn on Lest and right. 20 July
2008 undergone transvaginal ultrasound at AGRA. 30 1930 July 2008 for congenital scanning @ 28 weeks (august
12, 2008) or on next ultrasound. Vital sign ans FHT monitored and recorded.

Laboratory and Diagnostic Examinations Result

 Urinalysis Result
07/21/08

Macroscopic result Norm

exam
Color straw Straw, amber
Transparency S.I turbid clear
Reaction Acidic Acidic
Specific gravity 1.005 1.005-1.025
Sugar Negative Negative
Protein Negative Negative
Microscpic exam
RBC 0-2 0-1hpf
Pus Cell 0-2 0-2/hpf
Squamous few
Ephitilial cells

Hematology 04/30/08

Pt Value Reference range

Leukocyte count 9.8 x10 9/L 4.5-11.0
Leukocyte diff.
count
Neutrophils 0.67 0.35-0.65
 Eosinophils 0.03 0.00-0.05
Lymphocytes 0.30 0.20-0.40

Hemoglobin 110g/l 120-160

hematocrit 0.36 vol. frac 0.37-0.41

Ultrasound 1
Obstetrics Ultrasound Report
24 July 2008

Second and third trimester ultrasound report

Final impression:
Cephalic presentation, live singleton
No previa
Posterior placenta location]
Amniotic fluid volume: oligohydramnios (AFI=1.7cm)
Placental grade: grade 1
Pregnancy Uterine, 21 wks 3 days AOG by fetal biometry
Intramural myoma nodule, upper anterior (3.5 x 2.0)
With note of multicystic left kidney
Suggest congental anomaly scan at 24 weeks AOG.

Ultrasound 2
Obstetrics Ultrasound Report
7/28/2008
 2nd and 3rd trimester
Number of fetus: 1
Presentation: breech
Amniotic fluid volume: 39 (2vp)
Q1- 1.8
Q2- 2.1

Placenta location: fundus

Fetal Biometry
BPD - 52mm 21weeks 4days
HC - 192mm 21weeks 3days
AC - 163mm 21weeks 1day
FL - 35mm 22weeks 1day
AV Sonar age 21 weeks 4 days
Estimated date of delivery: 12/04
Wstimated fetal weight. 429 grams
Remarks: The amniotic Fluid index has improved slightly., but generally
scanning showed still with oligohydramnios
Generic Dosage/ Classificatio Indications Contraindicat Side effects Nursing
Name Frequency n ions Consideratio
ns
 Cues Nursing Analysis Planning Intervention Rationale Evaluation
Diagnosis

O- Risk for At risk of Goal: All the

Transabdomina Fetal Injury fetal injury After 4 hrs of nursing Nursing
l Ultrasound related to as a result intervention, the intervention
resulting in cord of client will verbalize rendered to
Oligohydramni compression environment understanding of the client
os secondary al conditions individual factors that were
to interacting contribute to appropriate,
decreased with the possibility of fetal efficient ,
amniotic individual’s injury and take steps effective and
fluid as adaptive to correct situation adequate for
manifested and the clients
bu Trans defensive Objective: condition.
abdominal resources After 4 hrs of nursing Through this
ultrasound intervention, the interventions
result. client will: the client
1. Assess clients 1. Assessment was been able
1 . Verbalize the ability to provide info to to verbalize
definition and understand guide planning an understandin
possible causes of teaching individualized g of individual
oligohydramnios teaching program factors that
to ensure the contribute to
clients possibility of
understanding fetal injury
and take
2 . Verbalize 2. Provide a steps to
complication and comfortable 2. Intervention correct her
effect of quite setting for decrease situation
oligohydramnios teaching and distraction and
to the baby invite family to promote learning;
participate family may
reinforce teaching
and help client
comply

3. Abide to the 3. Provide

doctors order and written
health teachings. information on 3. Accurate info
oligohydramnios encourages
about its causes, compliance and
effect and written resources
complication for later review
and self paced
4. Provide
information on 4. To enhance
 Cues Nursing Analysis Planning Intervention Rationale Evaluation
Diagnosis

Goal: All the

S- “ Ang alam Deficient Absence or After 4 hrs of nursing Nursing
ko lang pwede Knowledge Deficiency intervention, the intervention
malaglagan ng regarding of cognitive client will verbalize rendered to
bata pag Preterm information increase knowledge the client
ganun eh” as labor related to about preterm labor were
stated by the prevention specific appropriate,
client related to topic Objective: efficient ,
unfamiliarity (preterm After 4 hrs of nursing effective and
-“Sabi nila with labor intervention, the adequate for
pwede daw preterm prevention) client will: the clients
akong labor condition.
manganak ng 1. 1. Describe signs and 1 . Assess 1. Assessment Through this
wala sa symptom of preterm client’s risk provide to guide interventions
kabuwanan labor factor for planning an the client
pag ganun. preterm labor individualized was able to
Yun lang ang 2. Describe steps to and ability to teaching program verbalize
alam ko” as take to avoid preterm understand to ensure client understandin
stated by the labor teaching understanding. g about s/s of
client 2. preterm labor
2. Interventions and what’s its
-“ Hindi naman decrease possible
ako 2. Provide a distractions and prevention
naghihilab,gu comfortable promote learning;
magalaw lang quite setting for family may
yung baby sa teaching and reinforce teaching
tiyan ko” as invite family to and help client
stated by the participate in comply.
client session
3.Some clients
O- less anxiety 3. Assist clients may believe that
understanding of preterm infants
the risks of have few problems
preterm labor or that 7 month
and birth for her babies do better
baby. than 8 month
gestations(old
wives tale)

4. Assisting
4. Help client to empower the
identify Braxton- client to recognize
Cues Nursing Analysis Planning Intervention Rationale Evaluation
Diagnosis
 Goal: All the
O- doctors Deficient Decreased After 4 hrs of nursing Nursing
order to have Diversional stimulation intervention, the intervention
complete bed Activity from client will verbalize rendered to
rest with out related to recreational examples of the client
bathroom prescribed or leisure satisfying activities were
privileges complete activities. within personal limits appropriate,
bed rest efficient ,
without Objective: effective and
bathroom After 4 hrs of nursing adequate for
privileges intervention, the the clients
secondary client will: condition.
to preterm 1 .Determine 1. Presence of Through this
labor 1. 1. Be motivated and ability to depression, interventions
stimulate client participate in problem of the client
involvement in activities that are mobility, was able to
solution available protective verbalize
isolation, or understandin
2. Promote wellness 2.Acknowledge sensory g about s/s of
reality of situation deprivation may preterm labor
and feelings of the onterfere with and what’s its
client desired activity possible
prevention

3. Interventions
3. Provide for decrease
physical as well as distractions and
mental diversional promote
activities learning; family
may reinforce
teaching and
help client
 comply.

4. encourage mix 4.Some clients

of desired activity( may believe that
e.g., music, preterm infants
reading, news have few
program etc.) problems or that
7 month babies
do better than 8
month
gestations(old
wives tale)

5. Accept hostile
expressions while 5. Assisting
limiting aggressive empower the
acting-out client to
behavior recognize mild
uterine
contraction.
Many women are
unaware that
Braxton-Hicks
are contraction
even if they are
not painful
6. Make
appropriate
referrals to
available support 6. Teaching
groups, hobby promotes self
clubs, service care and
organizations assessment
skills. The
fundus is the
thickest part of
the uterus where
contractions are
most easily felt.

6. Teaching
promotes
awareness of
sensations of
contractions and
fetal movement.
Journal provides
a written record
of activity.

7. Teaching
empowers client
to recognize
subtle signs of
preterm labor.
Client may not
experience
contractions as
 such.

8. Dehydration
or a distended
bladder may
increase uterine
irritability/activit
y.

9. Instruction
avoids activity
that may cause
the release of
oxytocin from
posterior
pituitary gland.
Semen contains
prostaglandins
that may affect
uterine activity.

10. Instruction
allows client to
have some
evaluation of
preterm labor
 Prioritization:

Nursing Diagnosis Rank Justification

Risk for Fetal Injury 1 It is a life threatening
related to cord
compression secondary
to decreased amniotic
fluid as manifested bu
Trans abdominal
ultrasound result.
Deficient Knowledge
regarding Preterm labor
prevention related to
unfamiliarity with
preterm labor
Deficient Diversional
Activity related to
prescribed complete bed
rest without bathroom
privileges secondary to
preterm labor
situation that needs
immediate interventions.
2 It does not need
immediate interventions
because our nursing
intervention is only to
provide information about
preterm labor.
3 This nursing Dx is least
addressed because it
focuses on psychomotor
and it is not that life
threatening.
 ECOLOGIC MODEL

A. Hypothesis
Based on the gathered data and information, we presume that the fetus is the host, the mother is the agent and the
amniotic fluid is the environment. The mother acquired oligohydramnios because of certain factors such as decrease
fluid intake (1 liter/day)

B. Predisposing Factors

Agent We chose Agent-Host-Environment Model since according to her

diagnosis, too little amniotic fluid . This model is composed of
three dynamic, interactive elements. The Agent, a factor
Environment (biologic, chemical, physical, mechanical, psychosocial) that must
be present or absent for an illness to occur. In this case, the
Host Environment
agent will be the mother, Second, the host which is the fetus, a
st living being capable of being infected or affected by the agent.
Lastly, the environment, wherein everything external to the host
that makes illness more or less likely which is the amniotic fluid.
We know that when a single component of this model will be altered, a disease or illness will take place.

C. Conclusion and Recommendation

After analyzing the client’s predisposing factors that affect her condition, we conclude that the agent is the primary
factor that causes her to acquire her present condition. As stated by the client, she has inadequate gluid intake
before admission to the hospital.
As for the recommendation, we advise the client to continue her ongoing treatment for the promotion of her
wellness and her baby’s wellness and reduce further complication.

PATHOPHYSIOLOGY

(Can be associated)
Fetal abnormalities (growth restricted fetuses)

Redistribute blood flow away

from their kidneys,

Failure of fetal kidney development

Blocked urinary excretion

Decrease in fetal urine production

Decrease in amniotic fluid volume

(oligohydramnios)

Contractions occur or movements of the fetus in the womb

 Compression of the umbilical cord

Poor fetal lung development (pulmonary hypoplasia), malformations may result to compression of fetal parts, fetal
death