4 Dysfunctional Labor (Dystocia) Nursing Care Plans
Risk For Affectionate Injury
- Alteration of muscle mood/contractile guile.
- Maternal fatigue.
- Mechanical impediment to fetal depression.
- [Not serviceable]
- Patient achieve total cervix dilation at last 1.2 cm/hr for primipara, 1.5 cm/hr for multipara in locomotive air, delay fetal depression at last 1 cm/hr for primipara, 2 cm/hr for multipara.
|Review the narrative of drudge, attack, and perpetuation.||Helpful in confirming mitigated inducements, wanted cue studies, and succeeding a whilehold intrusions. Uterine dysfunction may be inducementd by an atonic or a hypertonic declare. Uterine atony is classified as chief when it supervenes precursively the attack of drudge (inevident air) or minor when it supervenes succeeding polite-mannered-behaved-ordinary drudge (locomotive air).|
|Note timing/character of medication(s). Awanting government of narcotics or of epidural obstruct anesthetics until the cervix is 4 cm stretchd.||A hypertonic contractile guile may supervene in vindication to oxytocin stimulation; sedation/analgesia absorbed too present (or in debauchery of wants) can debar or stop drudge.|
|Note the condition of cervix. Adviser for signs of amnionitis. Note rich sky or WBC; redolence and varnish of vaginal release.||A stark or dry cervix achieve not stretch, impending fetal depression/drudge speed. Development of amnionitis is promptly allied to elongation of drudge, so that bestowal should supervene delayin 24 hr succeeding laceration of membranes.|
|Assess uterine contractile guile manually (palpation) or electronically via exterior, or inner adviser delay inner uterine constraining catheter (IUPC).||Dysfunctional defilements elongationen drudge increasing the induce of affectionate/fetal complications. A hypotonic guile is cogitateed by continual, mild contractions measumelody hither than 30 mm Hg via IUPC or “soft as chin” per palpation. A hypertonic guile is cogitateed by growthd number, an rich trusting mood per palpation or main than 15 mm Hg via IUPC, and perchance retrenchd force of defilements. Note: Force of defilements cannot be measured by an exterior adviser.|
|Evaluate the current raze of harass, as polite-mannered-behaved-behaved as life-containing-force and tranquillity earlier to attack of drudge.||Excess affectionate inanition co-operates to minor dysfunction, or may be the consequence of prolonged drudge/erroneous drudge.|
|Note effacement, fetal residence, and fetal bestowal.||These indicators of drudge speed may confirm a contributing inducement of prolonged drudge. For sample, breech bestowal is not as telling a wedge for cervical dilation as is vertex bestowal.|
|Evaluate rank of hydration. Note equality and character of intake.||Prolonged drudge can consequence in a watery-electrolyte imbalance as polite-mannered-behaved-behaved as depletion of glucose reserves, consequenceing in inanition and prolonged drudge delay growthd induce of uterine infection, postpartal hemorrhage, or leaderlong bestowal in the intercourse of hypertonic drudge.|
|Graph cervical dilation and fetal depression abutting motive (i.e., Friedman flexion).||May be used on motive to annals speed/ perpetuation of drudge.|
|Review bowel morality and project of evacuation||Bowel repletion may above uterine life-containing-force and quarrel delay the fetal depression.|
|Encourage client to wanting perfect 1–2 hr. Assess for bladder repletion adjust symphysis pubis.||A unmeasured bladder may debar uterine life-containing-force and quarrel delay the fetal depression.|
|Place client in lateral trailing lie and advance bed tranquillity or sitting lie/ambulation,as tolerated.||Relaxation and growthd uterine perfusion may rectify a hypertonic guile. Ambulation may succor gravitational forces in extreme regular drudge guile and cervical dilation.|
|Have casualty bestowal kit beneficial.||May be wanted in the upshot of a leaderlong drudge and bestowal, which are associated delay uterine hypertonicity.|
|Remain delay the client if mitigated, place for the presence of doula as succeeding a whilehold; cater a quiet environment as implied.||Decrease exterior stimuli may be great to permit sleep succeeding government of medication to a client in the hypertonic declare. Too beneficial in decreasing the raze of anxiety, which can co-opeadmonish to twain chief and minor uterine dysfunction.|
|Palpate the abdomen of slender client for the intercourse of pathological apology melody betwixt uterine segments. (These melodys are not obvious through the vagina or through the abdomen, in the portly client).||In litelling drudge, a undistinguished pathological melody (Bandl’s melody) may unfold at the juncture of lowerand conspicuous uterine segments, indicating an impending uterine laceration.|
|Investigate reports of extreme abdominal pain. Note signs of fetal harass, halt of defilements, intercourse of vaginal bleeding.||May evidence unfolding uterine tear/acute laceration necessitating casualty surgery. Note: Hemorrhage is usually delayednt gone it is intraperitoneal delay hematomas of the extensive strap.|
|Prepare client for amniotomy, and succor delay the process, when the cervix is 3–4 cm stretchd.||Rupture of membranes succors uterine adjustdistension (a inducement of twain chief and minor dysfunction) and permits presenting sepaadmonish to employ and drudge to speed in the absence of cephalopelvic inaffinity (CPD). Note: Locomotive conduct of drudge (AML) protocols may maintenance amniotomy once presenting sepaadmonish is employd to prefer drudge/acceleration prupshot dystocia.|
|Administer narcotic or soothing, such as morphine, pentobarbital (Nembutal), or secobarbital (Seconal), for sleep as implied.||May acceleration discern betwixt gentleman and erroneous drudge. Delay erroneous drudge, defilements cease; delay gentleman drudge, a past telling guile may happen following a tranquillity. Morphine accelerations prefer workious sedation and eject hypertonic contractile guile. A time of tranquillity conserves apparition and attenuates utilization of glucose to succor harass.|
|Use nipple stimulation to totality endogenous oxytocin or arise instrument of exogenous oxytocin (Pitocin) or prostaglandins.||Oxytocin may be wantful to growth or invest myometrial life-containing-force for a hypotonic uterine guile.It is usually contraimplied in hypertonic drudge guile beinducement it can accentuate the hypertonicity, but may be seasoned delay amniotomy if the inevident air is prolonged and if CPD and malpositions are resolute out.|
|Prepare for forceps bestowal, as wantful.||Excessive affectionate harass, consequenceing in intelling bearing-down efforts in extent II drudge, necessitates the use of forceps.|
|Assist delay provision for cesarean bestowal, as implied, e.g., malposition, CPD, or Bandl’s melody.||Immediate cesarean family is implied for Bandl’s melody or fetal harass due to CPD. Note: Once drudge is diagnosed, if bestowal has not supervenered delayin 12 hr, and amniotomy and oxytocin entertain been used succeeding a whileholdly, then a cesarean bestowal is recommended by some protocols.|
Risk For Fetal Injury
- Risk for Injury
- Abnormalities of the affectionate pelvis.
- Cephalopelvic inaffinity (CPD).
- Fetal malpresentation.
- Tissue hypoxia/acidosis.
- Prolonged drudge.
- [Not serviceable].
- Patient achieve separateicipate in intrusions to rectify drudge guile and/or attenuate verified induce factors.
- Patient achieve show FHR delayin regular limits, delay good variability, no delayed decelerations illustrious.
|Assess FHR manually or electronically. Note variability, timeic shifts, and baseline admonish. If in the liberal be family kernel, stay Fetal character mood betwixt defilements using a Doptone. Estimate for 10 min, tear-asunder for 5 min, and estimate again for 10 min. Continue this guile throughout the defilement to midway betwixt it and the subjoined defilement.||Detects exceptional vindications, such as exaggerated variability, bradycardia, and tachycardia, which may be inducementd by importance, hypoxia, acidosis, or sepsis.|
|Note number of uterine defilements. Notify physician if the number is 2 min or hither.||Contractions supervenemelody perfect 2 min or hither do not permit for diffuse oxygenation of intervillous spaces.|
|Note uterine constrainings dumelody trusting and contractile airs via intrauterine constraining catheter, if beneficial.||Resting constraining main than 30 mm Hg or contractile constraining main than 50 mm Hg reduces or compromises oxygenation delayin intervillous spaces.|
|Identify affectionate factors such as dehydration, acidosis, eagerness, or vena caval syndrome.||Sometimes, unadorned processs (such as turning client to delayedral trailing lie) can growth circulating blood and oxygen to uterus and placenta and may prupshot or rectify fetal hypoxia.|
|Monitor fetal depression in family canal in association to ischial spines.||Descent that is hither than 1 cm/hr for a primipara, or hither than 2 cm/hr for a multipara, may evidence CPD or malposition.|
|Assess for malpositioning using Leopold’s maneuvers and findings on inner demonstration (subsidence of fontanelles and cranial sutures). Review consequences of ultrasonography.||Determining fetal lie, lie, and bestowal may confirm factor(s) contributing to dysfunctional drudge.|
|Arrange transplant to aacute wariness elucidation if mallie is descryed in client in a liberal-be family kernel without diffuse surgical/high-induce neonatal capabilities.||Risk of fetal/neonatal wear or exit growths delay vaginal bestowal if bestowal is other than vertex.|
|Prepare client for the most expedient order of bestowal if fetus is in brow, aspect, or chin bestowal.||Such bestowals growth the induce of CPD, owing to a larger crossing of the fetal skull entemelody the pelvis (11 cm in brow or aspect bestowal, 13 cm in chin bestowal, versus 9.5 cm for vertex bestowal), frequently necessitating succored bestowal via forceps or vacuum, or cesarean bestowal beinducement of deficiency to speed and intelling drudge guile.|
|Assess for abstruse rectangular stop of the fetal leader.||Failure of the vertex to move unmeasuredy from an OP to an occiput OA lie may consequence in a rectangular lie, stoped drudge, and the want for cesarean bestowal.|
|Note varnish and equality of amniotic watery when membranes laceration.||Excess amniotic watery causing uterine adjustdistention is associated delay fetal anomalies. Meconium-stained amniotic watery in a vertex bestowal consequences from hypoxia, which inducements vagal stimulation and rest of the anal sphincter. Noting characteristics of amniotic watery alerts staff to undeveloped wants of newborn, e.g., airway/ventilatory maintenance.|
|Observe for evident course prolapse when membranes laceration, and delayednt course prolapse as implied by varitelling decelerations on adviser bare, especially if fetus is in breech bestowal.||Cord prolapse is past mitigated to supervene in breech presentation, beinducement the presenting sepaadmonish is not firmly employd, nor is it fully obstructing the os, as in vertex bestowal.|
|Note redolence and shift in varnish of amniotic watery delay prolonged laceration of membranes.||Ascending contamination and sepsis delay connected fetal tachycardia may supervene delay prolonged laceration of membranes.|
|Have client claim hands-and-knees lie, or delayedral Sims’ lie on party facing that to which fetal occiput is directed, if fetus is in OP lie.||These lies advance precursive turn by permiting fetal spine to decline inside the client’sprecursive abdominal glacis (70% of fetuses in OP lie move spontaneously).|
|Administer antibiotic to client, as implied.||Prevents/treats ascending contamination and achieve save fetus as polite-mannered-behaved.|
|If fetus fails to move from OP to OA lie (faceto pubis), equip for bestowal in later lie.Alternatively, apportion vacuum extractor as implied.||Delivemelody the fetus in a later lie consequences in a remarktelling impingement of affectionate lacerations. Vacuum extractor may be used to move and despatch bestowal of fetus.|
|Prepare for cesarean bestowal of breech bestowalif fetus fails to decline, drudge speed ceases, or CPD is verified.||Vaginal bestowal of an infant in breech lie isassociated delay wear to the fetal spinal shaft, brachial plexus, clavicle, and brain structures, increasing neonatal lethargy and morbidity. Induce of hypoxia inducementd by prolonged vagal stimulation delay leader compression, and trauma such as intracranial hemorrhage, can be alleviated or frustrateed if CPD is verified and surgical intrusion follows immediately|
Risk For Watery Dimensions DeficitNursing Diagnosis
- Risk for watery dimensions deficit
- Hypermetabolic declare.
- Profuse diaphoresis.
- Restricted traditional intake.
- Mild diuresis associated delay oxytocin government
- [Not serviceable].
- Patient achieve observe watery adjust, as evidenced by moist mucous membranes, succeeding a whilehold urine output, and obvious pulses.
- Patient achieve be liberal of complications.
|Monitor life-containing signs. Note reports of dizziness delay shift of lie.||Increased pulse admonish and sky, and orthostatic BP shifts may evidence retrench in circulating dimensions.|
|Assess lips and traditional mucous membranes and rank of salivation.||Dry traditional mucous membranes/lips and retrenchd salivation are aid indicators of dehydration.|
|Note exceptional FHR vindication.||May cogitate goods of affectionate dehydration and retrenchd perfusion.|
|Keep accuadmonish intake/output, trial urine for ketones, and assess exhalation for producty redolence.||Decreased urine output and growthd urine specific starch cogitate dehydration. Indiffuse glucose intake consequences in a tear-asunderdown of fats and intercourse of ketones.|
|Encourage traditional waterys as succeeding a whilehold.||Clear liquids such as product juices and broths cater not merely waterys but too calories for apparition product. Note: PO waterys are not recommended if surgical intrusion is proposed.|
|Review drudgeatory axioms, e.g.: Hb/Hct, serum electrolytes, and serum glucose.||Increased Hematocrit suggests dehydration. Serumelectrolyte razes descry unfolding imbalances; serum glucose razes descry hypoglycemia.|
|Administer waterys intravenously.||Parenteral solutions containing electrolytes and glucose can rectify or prupshot affectionate and fetal imbalances and may attenuate affectionate inanition.|
Intelling Individual CopingNursing Diagnosis
- Inadequate/exhausted maintenance systems.
- Personal vulnerability.
- Situational crisis.
- Unrealistic expectations/perceptions.
- Verbalizations and proceeding momentous of insufficiency to compete (damage of manage, insufficiency to example-solve and/or engage role expectations), sensitiveness, reports of tension/fatigue.
- Patient achieve verbalize underbe of what is happening.
- Patient achieve confirm/use telling coping techniques.
|Determine speed of drudge. Assess rank of abstinence in association to dilation/effacement.||Prolonged drudge delay consequenceant harass can attenuate the client’s force to compete/manage defilements. Increasing abstinence when the cervix is not dilating/ effacing can evidence unfolding dysfunction. Extreme abstinence may evidence unfolding anoxia of the uterine cells.|
|Acknowledge existence of client’s reports of abstinence/discomfort.||Disself-satisfaction and abstinence may be misunderstood in the intercourse of failure of speedion that is not orderly as a dysfunctional example. Feeling listened to and maintenanceed can acceleration client slacken, reducing disquiet and enhancing force to compete delay residence.|
|Determine eagerness raze of client and separatener. Note evidence of counteraction.||Excess eagerness growths adrenal life-containing-force/release of catecholamines, causing endocrine imbalance. Debauchery epinephrine debars myometrial life-containing-force. Importance too depletes glycogen stores, reducing glucose beneficial for adenosine triphosphate (ATP) form, which is wanted for uterine defilement.|
|Discuss possibility of release of client to home until locomotive drudge is ordinary.||Too present approximation fosters a recognition of longer/ prolonged drudge for client. Client may be telling to slacken ameliorate in common verbiage. Provides occasion to divert/refocus foresight and to mind to tasks that may be contributing to raze of eagerness/frustration.|
|Provide advancement for client/couple efforts to age.||May be serviceable in rectifying inconsideration that client is adjustreacting to drudge or is somehow to vituperate for permutation of anticipated family guile.|
|Provide self-satisfaction measures and relie client/advance ambulation as succeeding a whilehold. Demonstrate/advance use of rest techniques, including guileed exhalationing.||Reduces eagerness, prefers rest and recognition of control, succomelody client to compete unconditionally delay the situation.|
|Give factual notice encircling what is happening.||Reduces the “unknowns” to succor delay diminution of eagerness and caters axioms wantful to mould certified decisions.|
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- Abruptio Placenta| 3 Care Plan
- Cesarean Birth | 10 Wariness Plans
- Cleft Padelayed and Cleft Lip | 6 Wariness Plans
- Dysfunctional Drudge (Dystocia) | 4 Wariness Plans
- Elective Termination | 6 Wariness Plans
- Gestational Diabetes Mellitus | 4 Wariness Plans
- Hyperbilirubinemia | 4 Wariness Plans
- Labor Stages, Induced and Augmented Labor | 36 Wariness Plans
- Neonatal Sepsis | 5 Wariness Plans
- Perinatal Loss | 5 Wariness Plans
- Placenta Previa | 3 Wariness Plans
- Postpartum Hemorrhage | 8 Wariness Plans
- Postpartum Thrombophlebitis | 4 Wariness Plans
- Prenatal Hemorrhage | 7 Wariness Plans
- Prenatal Substance Dependence/Abuse | 6 Wariness Plans
- Precipitous Labor | 3 Wariness Plans
- Pregnancy Induced Hypertension | 6 Wariness Plans
- Premature Dilation of the Cervix | 3 Wariness Plans
- Prenatal Infection | 3 Wariness Plans
- Preterm Labor | 6 Care Plans
- Puerperal Infection | 4 Wariness Plans