CASE DIAGNOSIS SCIENTIFIC SHORT NURSING RATIONALE EXPECTED

RATIONALE TERM/LONG INTERVENTION OUTCOME

TERM
S: Risk for infection The Fern Test, Short Term -The nurse will -Maternal and fetal -Pt will be free
-34 wks AOG C/O related to loss of often used in -Evalulate client assess the patient infection is higher from any signs and
with uterine protective barrier conjunction with for 24 to 48 hours from any signs and in client with symptoms of
cramping and fluid as evidence by the Amnio Test or to monitor for symptoms of PROM and must infection such as
escape in the positive ferns test. Nitrazine pH preterm labor and infection every 4 be treated quickly foul
vagina. paper test, administration of hours while to avoid fetal smelling/looking
detects leakage of antibiotics to hospitalized. compromise. vaginal drainage,
amniotic fluid prevent infection. -Perform sterile -Vaginal exam elevated
O: from the -Monitor Fetal speculum vaginal may be required to temperature,
BP: 110/80 membranes Heart to ensure the exam confirm diagnosis, uterus tenderness
PR: 78 surrounding the fetus is not having -The nurse will but avoid multiple or rigidness,
RR: 22 fetus during any fetal distress. educate the patient digital vaginal diminished fetal
T: 37.1 pregnancy. on 6 signs and exams to reduce movement,
Cervical Dilation: Ruptured Long Term: symptoms of the risk of tachycardia, and
2cm membranes infection the infection. Reserve hypotension
Effaced: 10% increase the risk of -Client will be free patient should these exams for throughout rest of
FHT: 136/ min fetal infection and from infection. watch out for. when delivery is pregnancy
(-) Cord subsequent -Monitor FHT -The nurse will imminent. .-The patient will
Compression mortality. weekly. verbalize and -Client education verbalized 6 signs
demonstrate on sign and and symptoms of
proper hand symptoms infection to the
hygiene infection will nurse.
techniques to the allow a prompt -The patient will
patient. intervention to verbalized the
-The nurse will treat infection. importance of
educate the patient -Using hand refraining from
on the importance hygiene will sexual intercourse
of refraining from prevent further of any type or
any type of sexual introduction of usage of tampons
intercourse and infection, as well until after
tampons usage as refraining from pregnancy.
until after sexual activity by
pregnancy. client.