FORMULATE NCP WITH THE DIAGNOSIS OF PERINIAL INJURY RELATED
FORMULATE NCP WITH THE DIAGNOSIS OF PERINIAL INJURY RELATED TO… FORMULATE NCP WITH THE DIAGNOSIS OF PERINIAL INJURY RELATED TO MACROSOMIA AND SECONDARY TO GESTATIONAL DIABETES. Give at least 5 implementations.CASE SCENARIO:You are assigned at the Labor and Delivery Room in Ilocos Training and Regional Medical Center (ITRMC). Your Clinical Instructor assigned and instructed you to assists and to monitor the vital signs of the mother especially the blood pressure and the fetal heart tone of the baby.HISTORY:Cherry Blossom is a 30-year-old woman who is a G2 P0 has been admitted to labor and delivery at 39 weeks after her membranes ruptured at home. Her first baby was born vaginally 2 years ago but the baby was stillborn. She was diagnosed with gestational diabetes at 28 weeks and has been on insulin during the last trimester. Her records indicate that she is carrying a single pregnancy in vertex presentation via ultra-sound. Her past medical history is uncomplicated, she has no allergies and she take no medication other than the prenatal vitamins (folic acids and Iron supplements).Her most recent vital signs minutes ago were as follows: BP 110/70, Pulse 69 beats per minute, Respiratory rate of 20 breaths per minute and Temperature of 36.8 C. In the delivery room the mother has been pushing for 2 ½ hours and is becoming exhausted. (“I am so tired” I can’t push anymore!”) She agreed to have saline lock placed with prolonged labor. Fetal heart tones has been complicated (160 to 180 bpm). Her contractions occurred every 2 to3 minutes lasting 60 seconds, strong to palpation. Her blood sugars have all been less than 90 mg/dl, so her insulin drip has been on hold for the last couple of hours.As the baby crowns, the fetal heart rate decelerates to the 100 bpm with pushing. There is a fluctuation of FHR. The baby’s head has retracted onto the perineum. The rest of the body was not able to be delivered within 30 seconds because of shoulder dystocia and there was also cord loop. The nurses and doctors performed McRoberts maneuver and suprapubic pressure to deliver the baby in the labor/delivery room but the McRoberts maneuver and suprapubic pressure was not effective at all so the doctor decided to have an episiotomy due to prolong labor secondary to large baby and cord loop. After the delivery, there was vaginal lacerations despite of episiotomy. Episiorrhaphy and perineorrhaphy was done.Finally the baby delivered with a APGAR score of 5 and the mother’s vital signs are as follows: BP 140/90 PR 110bpm, RR 25bpm and Temp 36.6. The patient was ok but tired and restless.OTHER INFORMATION:Cherry Blossom has her menstruation at the age of 11 with irregular flow. (1 to 2 days only). She married for 8 years to Mr. Dwan Blosson who is an OFW and they are using condom as contraceptives. She has gestational diabetes and taking insulin injections (metformin) once daily. ASSESSMENTNURSING DIAGNOSISPLANNINGIMPLEMENTATIONRATIONALEEVALUATIONSUBJECTIVE:PERINIAL INJURY RELATED TO MACROSOMIA AND SECONDARY TO GESTATIONAL DIABETES INDEPENDENT: DEPENDENT: OBJECTIVE: COLLABORATIVE: Health Science Science Nursing
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