- Dysfunctional work is arduous, ulcerous, prolonged work due to unreflective contents.
- Fetal contents (passenger) embody unusually ample fetus, fetal informality, malpresentation, and malposition
- Uterine contents (powers) embody hypotonic work, hypertonic work, rash work, and prolonged work.
- Pelvic contents (passage) embody commencement contracture, midpelvis contracture, and exit contracture.
- “Psyche” contents embody affectionate solicitude and dismay and delaydrawal of provision.
- Uterine defilements are undignified outcomeant to muscle weary or aggravatestretching.
- Clinical manifestations embody disorderly uterine defilements and undignified uterine defilements in stipulations of contractile ability and continuance.
- Optimize uterine essence. Mentor uterine defilements for dysfunctional exemplars; use palpation and an electronic mentor.
- Prfact uncalled-for weary. Repress the client’s flatten of weary and ability to compete delay refusal.
- Prfact complications of work for the client and infant.
- Assess urinary bladder; catheterize as deficiencyed.
- Assess affectionate considerefficacious signs, including sky, pulse, respiratory objurgates, and respect hurry.
- Check affectionate urine for acesound (an token of dehydration and inanition).
- Assess stipulation of fetus by mentomelody FHR, fetal essence, and pretense of amniotic soft.
- Provide perceptible and emotional succorance.
- Promote pause through bathing and guardianship the client and bed clear, tail rubs, continual posture fluctuates (sidelying), walking (if involved), and by guardianship the environment tranquillize.
- Coach the client in inhalationing and pause techniques.
- Provide client and rise counsel.
Dysfunctional Work (Dystocia) Practice Exam (PM)*
Nursing Caution Plan
Risk For Fluid Bulk Deficit
- Hypermetabolic avow.
- Profuse diaphoresis.
- Restricted traditional intake.
- Mild diuresis associated delay oxytocin government
Possibly evidenced by
- [Not convenient].
- Patient conclude repress soft equalize, as evidenced by moist mucous membranes, divert urine output, and corpspoken pulses.
- Patient conclude be exempt of complications.
|Monitor considerefficacious signs. Silence reports of dizziness delay fluctuate of posture.||Increased pulse objurgate and sky, and orthostatic BP fluctuates may manifest decrreadiness in circulating bulk.|
|Assess lips and traditional mucous membranes and class of salivation.||Dry traditional mucous membranes/lips and abated salivation are further indicators of dehydration.|
|Note abnatural FHR exculpation.||May return goodss of affectionate dehydration and abated perfusion.|
|Keep accuobjurgate intake/output, test urine for ketones, and assess inhalation for rewardy trail.||Decreased urine output and extensiond urine specific dismally return dehydration. Inextensive glucose intake outcomes in a fracturedown of fats and closeness of ketones.|
|Encourage traditional softs as divert.||Clear liquids such as reward juices and broths adapt not simply softs but so calories for apparition origination. Note: PO softs are not recommended if surgical interlasting is proposed.|
|Review workatory axioms, e.g.: Hb/Hct, serum electrolytes, and serum glucose.||Increased Hematocrit suggests dehydration. Serumelectrolyte flattens discaggravate lay-opening imbalances; serum glucose flattens discover hypoglycemia.|
|Administer softs intravenously.||Parenteral solutions containing electrolytes and glucose can chasten or prfact affectionate and fetal imbalances and may shorten affectionate inanition.|
Risk For Maternal Injury
- Alteration of muscle tone/contractile exemplar.
- Maternal fatigue.
- Mechanical aboveance to fetal depression.
Possibly evidenced by
- [Not convenient]
- Patient conclude conclude cervix dilation at meanest 1.2 cm/hr for primipara, 1.5 cm/hr for multipara in exempt interest, delay fetal depression at meanest 1 cm/hr for primipara, 2 cm/hr for multipara.
|Review the truth of work, onslaught, and continuance.||Helpful in establishing implicit origins, deficiencyed cue studies, and divert interpositions. Uterine dysfunction may be origind by an atonic or a hypertonic avow. Uterine atony is classified as principal when it betides antecedently the onslaught of work (implicit interest) or outcomeant when it betides succeeding polite-established work (exempt interest).|
|Note timing/image of medication(s). Aempty government of narcotics or of epidural obstruct anesthetics until the cervix is 4 cm expandd.||A hypertonic contractile exemplar may betide in exculpation to oxytocin stimulation; sedation/analgesia ardent too existing (or in superfluity of deficiencys) can debar or delayhold work.|
|Note the stipulation of cervix. Mentor for signs of amnionitis. Silence considerefficacious sky or WBC; trail and pretense of vaginal execute.||A unflexible or harsh cervix conclude not expand, threatening fetal depression/work advancement. Development of amnionitis is instantly cognate to elongation of work, so that introduction should betide delayin 24 hr succeeding breach of membranes.|
|Assess uterine contractile exemplar manually (palpation) or electronically via apparent, or interior mentor delay interior uterine hurry catheter (IUPC).||Dysfunctional defilements elongate work increasing the raise of affectionate/fetal complications. A hypotonic exemplar is returned by continual, mild contractions measumelody short than 30 mm Hg via IUPC or “soft as chin” per palpation. A hypertonic exemplar is returned by extensiond abundance, an considerefficacious hanging sound per palpation or elder than 15 mm Hg via IUPC, and haply abated concentration of defilements. Note: Concentration of defilements cannot be measured by an apparent mentor.|
|Evaluate the ordinary flatten of weary, as polite as essence and pause preceding to onslaught of work.||Excess affectionate inanition gives to outcomeant dysfunction, or may be the outcome of prolonged work/fiction work.|
|Note unindicativeness, fetal colonization, and fetal donation.||These indicators of work advancement may establish a contributing origin of prolonged work. For in, breech donation is not as goodsive a wedge for cervical dilation as is vertex donation.|
|Evaluate class of hydration. Silence total and image of intake.||Prolonged work can outcome in a soft-electrolyte imequalize as polite as depletion of glucose reserves, outcomeing in inanition and prolonged work delay extensiond raise of uterine infection, postpartal hemorrhage, or rash introduction in the closeness of hypertonic work.|
|Graph cervical dilation and fetal depression repeatedlyst interval (i.e., Friedman flexion).||May be used on find to reregularity advancement/ prolongation of work.|
|Review bowel conduct and consecutiveness of evacuation||Bowel plethora may above uterine essence and quarrel delay the fetal depression.|
|Encourage client to empty whole 1–2 hr. Assess for bladder plethora aggravate symphysis pubis.||A generous bladder may debar uterine essence and quarrel delay the fetal depression.|
|Place client in indirect horizontal posture and tolerate bed pause or sitting posture/ambulation,as tolerated.||Relaxation and extensiond uterine perfusion may chasten a hypertonic exemplar. Ambulation may succor gravitational forces in lively natural work exemplar and cervical dilation.|
|Have necessity introduction kit beneficial.||May be deficiencyed in the fact of a rash work and introduction, which are associated delay uterine hypertonicity.|
|Remain delay the client if implicit, range for the presence of doula as divert; adapt a tranquillize environment as involved.||Decrreadiness apparent stimuli may be considerefficacious to sanction drowse succeeding government of medication to a client in the hypertonic avow. So succorful in decreasing the flatten of anxiety, which can give to twain principal and outcomeant uterine dysfunction.|
|Palpate the abdomen of unsubstantial client for the closeness of pathological retrexercise melody betwixt uterine segments. (These melodys are not corpspoken through the vagina or through the abdomen, in the fertile client).||In compulsory work, a undistinguished pathological melody (Bandl’s melody) may lay-open at the juncture of lowerand remarkefficacious uterine segments, indicating an threatening uterine breach.|
|Investigate reports of rigorous abdominal pain. Silence signs of fetal vex, abeyance of defilements, closeness of vaginal bleeding.||May manifest lay-opening uterine tear/acute breach necessitating necessity surgery. Note: Hemorrhage is usually secret since it is intraperitoneal delay hematomas of the generic bond.|
|Prepare client for amniotomy, and succor delay the act, when the cervix is 3–4 cm expandd.||Rupture of membranes accelerations uterine aggravatedistension (a origin of twain principal and outcomeant dysfunction) and sanctions presenting portio to gain and work to advancement in the omission of cephalopelvic incongruity (CPD). Note: Exempt government of work (AML) protocols may succorance amniotomy once presenting portio is gaind to acceleobjurgate work/succor prfact dystocia.|
|Administer somniferous or composing, such as morphine, pentobarbital (Nembutal), or secobarbital (Seconal), for drowse as involved.||May succor characterize betwixt penny and fiction work. Delay fiction work, defilements cease; delay penny work, a aggravate goodsive exemplar may happen following a pause. Morphine succors exalt impenetrefficacious sedation and segregate hypertonic contractile exemplar. A span of pause conserves apparition and shortens utilization of glucose to acceleration weary.|
|Use nipple stimulation to profit endogenous oxytocin or originate absorption of exogenous oxytocin (Pitocin) or prostaglandins.||Oxytocin may be indispensefficacious to incrreadiness or begin myometrial essence for a hypotonic uterine exemplar.It is usually contrainvolved in hypertonic work exemplar beorigin it can accentuate the hypertonicity, but may be adept delay amniotomy if the implicit interest is prolonged and if CPD and malpositions are resolute out.|
|Prepare for forceps introduction, as indispensable.||Excessive affectionate weary, outcomeing in undignified bearing-down efforts in quality II work, necessitates the use of forceps.|
|Assist delay provision for cesarean introduction, as involved, e.g., malposition, CPD, or Bandl’s melody.||Immediate cesarean nativity is involved for Bandl’s melody or fetal vex due to CPD. Note: Once work is diagnosed, if introduction has not betidered delayin 12 hr, and amniotomy and oxytocin entertain been used divertly, then a cesarean introduction is recommended by some protocols.|
Risk For Fetal Injury
- Abnormalities of the affectionate pelvis.
- Cephalopelvic incongruity (CPD).
- Fetal malpresentation.
- Tissue hypoxia/acidosis.
- Prolonged work.
Possibly evidenced by
- [Not convenient].
- Patient conclude portioicipate in interpositions to amend work exemplar and/or shorten attested raise contents.
- Patient conclude evidence FHR delayin natural limits, delay good variability, no delayed decelerations silenced.
|Assess FHR manually or electronically. Silence variability, spanic fluctuates, and baseline objurgate. If in the exempt lasting nativity benevolence, repress Fetal interior sound betwixt defilements using a Doptone. Reckon for 10 min, fracture for 5 min, and reckon repeatedly for 10 min. Continue this exemplar throughout the contrexercise to midway betwixt it and the succeedingcited defilement.||Detects abnatural exculpations, such as exaggerated variability, bradycardia, and tachycardia, which may be origind by stress, hypoxia, acidosis, or sepsis.|
|Note abundance of uterine defilements. Notify physician if the abundance is 2 min or short.||Contractions betidemelody whole 2 min or short do not sanction for extensive oxygenation of intervillous spaces.|
|Note uterine hurrys dumelody hanging and contractile interests via intrauterine hurry catheter, if beneficial.||Resting hurry elder than 30 mm Hg or contractile hurry elder than 50 mm Hg reduces or endangers oxygenation delayin intervillous spaces.|
|Identify affectionate contents such as dehydration, acidosis, solicitude, or vena caval syndrome.||Sometimes, arthither acts (such as turning client to indirect horizontal posture) can extension circulating blood and oxygen to uterus and placenta and may prfact or chasten fetal hypoxia.|
|Monitor fetal depression in nativity canal in relevancy to ischial spines.||Descent that is short than 1 cm/hr for a primipara, or short than 2 cm/hr for a multipara, may manifest CPD or malposition.|
|Assess for malpositioning using Leopold’s maneuvers and findings on interior test (colonization of fontanelles and cranial sutures). Review outcomes of ultrasonography.||Determining fetal lie, posture, and donation may establish content(s) contributing to dysfunctional work.|
|Arrange remand to aacute caution enhancement if malposture is discovered in client in a exempt-lasting nativity benevolence without extensive surgical/high-raise neonatal capabilities.||Risk of fetal/neonatal impairment or release extensions delay vaginal introduction if donation is other than vertex.|
|Prepare client for the most judicious regularity of introduction if fetus is in brow, reckonenance, or chin donation.||Such donations incrreadiness the raise of CPD, owing to a ampler bisection of the fetal skull entemelody the pelvis (11 cm in brow or countenance donation, 13 cm in chin donation, versus 9.5 cm for vertex donation), frequently necessitating succored introduction via forceps or vacuum, or cesarean introduction beorigin of scarcity to advancement and undignified work exemplar.|
|Assess for submerged crosswise delayhold of the fetal summit.||Failure of the vertex to turn generousy from an OP to an occiput OA posture may outcome in a crosswise posture, delayholded work, and the deficiency for cesarean introduction.|
|Note pretense and total of amniotic soft when membranes breach.||Excess amniotic soft causing uterine aggravate distention is associated delay fetal anomalies. Meconium-stained amniotic soft in a vertex donation outcomes from hypoxia, which origins vagal stimulation and pause of the anal sphincter. Noting characteristics of amniotic soft alerts staff to implicit deficiencys of newborn, e.g., airway/ventilatory succorance.|
|Observe for perceptible regularity prolapse when membranes breach, and secret regularity prolapse as involved by variefficacious decelerations on mentor dismantle, especially if fetus is in breech donation.||Cord prolapse is aggravate mitigated to betide in breech presentation, beorigin the presenting portio is not firmly gaind, nor is it altogether obstructing the os, as in vertex donation.|
|Note trail and fluctuate in pretense of amniotic soft delay prolonged breach of membranes.||Ascending contamination and sepsis delay connected fetal tachycardia may betide delay prolonged breach of membranes.|
|Have client divert hands-and-knees posture, or indirect Sims’ posture on interest contradictory that to which fetal occiput is directed, if fetus is in OP posture.||These postures tolerate antecedent reversion by sanctioning fetal spine to set internal the client’santecedent abdominal bastion (70% of fetuses in OP posture turn spontaneously).|
|Administer antibiotic to client, as involved.||Prevents/treats ascending contamination and conclude fortify fetus as polite.|
|If fetus fails to turn from OP to OA posture (faceto pubis), adapt for introduction in subsequent posture.Alternatively, direct vacuum extractor as involved.||Delivemelody the fetus in a subsequent posture outcomes in a eminent impact of affectionate lacerations. Vacuum extractor may be used to turn and despatch introduction of fetus.|
|Prepare for cesarean introduction of breech donationif fetus fails to set, work advancement ceases, or CPD is attested.||Vaginal introduction of an infant in breech posture isassociated delay impairment to the fetal spinal post, brachial plexus, clavicle, and brain structures, increasing neonatal death and morbidity. Raise of hypoxia origind by prolonged vagal stimulation delay summit compression, and trauma such as intracranial hemorrhage, can be alleviated or intercepted if CPD is attested and surgical interlasting follows immediately|
Intelling Individual Coping
May be cognate to
- Inadequate/exhausted succorance systems.
- Personal vulnerability.
- Situational crisis.
- Unrealistic anticipateations/perceptions.
Possibly evidenced by
- Verbalizations and deportment expressive of impecuniosity to compete (detriment of curb, impecuniosity to collection-solve and/or as role anticipateations), excitability, reports of tension/fatigue.
- Patient conclude verbalize underlasting of what is happening.
- Patient conclude establish/use goodsive coping techniques.
|Determine advancement of work. Assess class of refusal in relevancy to dilation/effacement.||Prolonged work delay outcomeant weary can shorten the client’s ability to compete/husband defilements. Increasing refusal when the cervix is not dilating/ effacing can manifest lay-opening dysfunction. Extreme refusal may manifest lay-opening anoxia of the uterine cells.|
|Acknowledge truth of client’s reports of refusal/discomfort.||Disreadiness and refusal may be misunderstood in the closeness of delaydrawal of advancemention that is not stated as a dysfunctional collection. Feeling listened to and succoranceed can succor client release, reducing disreadiness and enhancing ability to compete delay nativity.|
|Determine solicitude flatten of client and portioner. Note evidence of defeat.||Excess solicitude extensions adrenal essence/relreadiness of catecholamines, causing endocrine imbalance. Excess epinephrine debars myometrial essence. Stress so depletes glycogen stores, reducing glucose beneficial for adenosine triphosphate (ATP) union, which is deficiencyed for uterine defilement.|
|Discuss possibility of execute of client to home until exempt work is established.||Too existing avenue fosters a appreciation of longer/ prolonged work for client. Client may be efficacious to release ameliorate in intimate dressing. Provides convenience to divert/refocus observation and to watch to tasks that may be contributing to flatten of solicitude/frustration.|
|Provide toleratement for client/couple efforts to date.||May be adapted in chastening carelessness that client is aggravatereacting to work or is somehow to reprehend for change of anticipated nativity drawing.|
|Provide readiness measures and reposture client/tolerate ambulation as divert. Demonstrate/tolerate use of pause techniques, including exemplared inhalationing.||Reduces solicitude, exalts pause and appreciation of control, succomelody client to compete categorically delay the situation.|
|Give factual notification encircling what is happening.||Reduces the “unknowns” to succor delay diminution of solicitude and adapts axioms indispensefficacious to find apprised decisions.|