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Priority Nursing Diagnosis Goals/Outcomes Nursing Interventions Rationale Evaluations

Risk for infection r/t The neonates’ vital signs 1. Review maternal chart and 1. This detects risk factors that 1. Mother received antibiotics during the
neonate’s immature will remain within normal delivery record. predispose neonate to infection latent phase of the first stage of labor in
immune system, possible range, while remaining alert and determine adequate order to prevent spreading of pathogen
GBS and active without signs or treatment before delivery. to the neonate at the time of delivery.
symptoms of infection.
2. Washing hands before and 2. Hand washing is the single 2. Patient was able to state the risk
after providing care, following best way to avoid spreading factors that can lead to infection;
Supportive Data: aseptic technique before and pathogens. “Washing my hands will help me
Mother has had history of after handling neonate. prevent spreading an infection to my
GBS (group B baby.”
streptococcus) and lab
results were positive for
infection. Goal/outcomes 3. Assessing the neonates’ 3. Passive immunity of neonate 3. Neonates’ gestational age was 38.6,
attainment: gestational age. via placenta increases indicates term neonate which reduces
significantly in the last susceptibility to infections.
Outcomes attained: trimester, making premature
Pt.’s VS remained within neonates much more
normal limits, without signs susceptible to infections.
or symptoms of infection,
while remaining alert and 4. Assess respirations, pulse, 4. Unstable vital signs, 4. Neonates’ vital signs remained stable
active in mothers’ arms. and blood pressure every 15 persistent elevations in with no elevation in temperature or
(VS: Resp: 58, HR: 143, minutes for 1hour, then every temperature, or hypothermia hypothermia.
B/P: 80/45, Temp: 97.8) hour for 4 hours, then once per may indicate neonatal infection. (Resp: 58 HR: 143, BP:
shift or more frequently as 80/45, TEMP: 97.8).
indicated.

5. Encourage mother to begin 5. Colostrum and breast milk 5. After mother received neonate in her
breastfeeding early. contain high amounts of arms, she was able to draw the neonate
immunoglobulin A, which to her breast while helping the neonate
provides passive immunity to properly latch on, she was able to
neonate and helps reduce verbalize the importance of colostrum
infection. and breast milk, “Though my milk has
not come in and it might seem my baby
is not getting enough, this is full of the
nutrients the baby needs for now, and
this will also help my baby’s immune
system.”
Students Name: Iris Lopez Date: 2/2/11

Client Summary: Obstetrical History: EDC: 2/4/2011 Gestational age: 38.6


G: 3 P: 2 T: 2 P: 0 A: 0 L: 2

Significant history and pregnancy complications: History of positive GBS

Summary of labor and delivery process:


Stage 1 latent phase: FHR 143, BP 118/81, contractions 5 minutes, 50-80 seconds duration. Patient grimacing, fidgety, not
able to keep same position for more than 3-5 minutes, verbalizing the feeling of a large amount of pressure in the perineal area.

Active phase: FHR 135, B/P 118/80, contractions 2-3 minutes, 40-70 second duration, patients epidural was placed in her
back; she stated the feeling of numbness in her lower extremities and a decrease in pain but no decrease in the feeling of
pressure in the perineal area. Demeanor was more relaxed and patient was drowsy after epidural medication was started,
patient positive for GBS, antibiotics were administrated within limits before expulsion of the infant.

Transition phase: FHR 143, B/P 118/81, contractions 1-2 minutes, 10-20 seconds duration, patient in lithotomy position with
hands wrapping around thighs to help in the expulsion of the fetus----the primary nurse and doctor were instructing patient not
to bear down, since she was not able to feel the contractions she was unable to use the contraction to her advantage which was
making her feel more pressure and pain-----she was moaning and groaning with low screams due to pain.

Stage II: Patient was able to use contractions to her advantage, though at one, time instead of using her hands wrapped around
her thighs, she lifted herself off the lithotomy position with her hands---- both the primary nurse and doctor instructed her to
use her hands and thighs, my fellow student and I were instructed to help her understand why she needed to keep her sacral
area on the bed-----she was expressing pain through moaning and groaning with low screams, her eyes bulged when bearing
down, patient was verbalizing that she was not able to go through the expulsion of the infant, she was effaced 100% and
dilated 10cm, a few minutes later the infant was delivered, baby birth weight 8lbs, 20 inches long, VS within normal limits,
APGAR of 8, pink with slight bluish color to soles of feet and palms of hands, given to mother for bonding, the parents were
very happy and expressing gratitude for everyone’s help.

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