Sie sind auf Seite 1von 1

Assessment Cues: Subjective: Nakikita ko may kasamang dugo sa napkin ko pagihi ko as verbalized by the client Objective: - blood in urine

-G4P0 (0210) V/S taken as follows: T: 36.7 P: 110 R: 21 Bp: 110/60

Diagnosis Risk for Maternal Injury related to premature cervical dilation as manifested by threatened abortion

Nursing Implication Premature cervical dilation previously termed as incompetent cervix refer in a cervix that dilates prematurely and therefore cannot hold a fetus until term that increase the risk to the mother injury Maternal & child health nursing: care of the childbearing & childrearing family: Chapter 21 pg. 563 by Adelle Pilliteri Goals:

Planning

Interventions Independent:

Rationale

Evaluation After 8 hours of nursing intervention, the patient have no vaginal bleeding. Goal was met.

After 8 hours of nursing intervention, the patient will experience no vaginal bleeding.

1.

Monitor vital signs closely

Changes in vital signs (e.g., elevated temperature or pulse, decreasing BP) may indicate infection or shock Vaginal bleeding other than slight spotting may be sign of cervical dilatation. Leaking membranes may herald impending delivery and place client at greater risk for infection. Prompt intervention lessens likelihood of complications The procedure is not done if vaginal bleeding or cramping is present, if membranes are ruptured, if cervical dilation greater than 3 cm occurs, or if the diagnosis of cervical dysfunction is in question because situation has progressed and spontaneous abortion is inevitable. A cesarean birth may be planned if the suture is left intact, or the suture may be removed, allowing a vaginal delivery. Note: Scar tissue may interfere with normal intrapartal cervical dilation and effacement A common side effect is maternal/fetal tachycardia; rare side effects include flushing, pulmonary

2.

Note presence of vaginal bleeding, leaking amniotic fluid, or uterine contraction

3.

Notify physician of abnormal findings or signs of labor

4.

Assess for presence of contraindications for cerclage procedure

5.

Review implication of cerclage procedure on outcome of delivery at term.

6.

Monitor for side effects of drugs used to