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Untitled Prezi No description by dre gaurana on 12 February 2013 •
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Transcript of Untitled Prezi CASE Eva Fonda, 17 years old and A G1P0, was 32 weeks pregnant when she found out that her boyfriend, a 35 y.o. policeman, had another family. Two days later, she was rushed to the nearest BEmOC facility because of frequent uterine contractions and excessive bleeding. She looks pale and already had 3 sanitary pads soaked with blood for 1 hour. She said, " daw malipong na ko..," the moment she arrived at the center. Upon assessment and internal examination, her capillary nail refill is beyond 2 seconds, poor skin turgor and sunken eyes, blood pressure is 80/60 mmhg, never had prenatal check ups even though she lives only an hour away from the center, and she's on active phase of labor with 9 cm cervical dilatation with 80% effacement. The previous night, she went to a "hilot" or abortionist because she doesn't want the baby anymore. She drank 3 glasses full of herbal concoction and when she lay down the table, she felt guilty and hurriedly left. Full transcript After the referral, she then traveled for 45 minutes to the CEmOC facility. When she arrived there, she was already fully dilated with the baby at station +2. The doctor then ordered blood type O negative to be transfused and prepared the woman for vaginal delivery. A 1,500 gram baby boy was delivered with an Apgar score of 6/10 in the first minute.( A=1 P:2 G: 1 A:1 and R: 1. The baby was breathing less than 30 breaths per minute with nasal flaring. As the nurse at the BEmOC and CEmOC facility what will be your nursing interventions to the mother and the baby? Supposedly the baby obtains an Apgar score of 8/10 (22112) after 5 minutes. What will be your proper nursing interventions NURSING CARE PLAN
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(BABY) Cues: Objective: More prezis by author
-Preterm birth(32 weeks) -Respiratory rate of less than 30 breaths per minute -Nasal flaring
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Vital Signs (baseline) T: 37 Degrees Celsius P: 105 bpm R: 20bpm Nursing Diagnosis Ineffective breathing pattern related to immature pulmonary functioning as evidenced by preterm birth (32 weeks), Respiratory rate of less than 30 breaths per minute, and nasal flaring Outcome Criteria After 15-30 minutes of effective nursing interventions, the infant will maintain normal respiration of 30-60 breaths per minute. ( According to Delmar’s Pediatric Nursing Care Planes, premature infants have dynamic respirations until the first 15 minutes of life, after which, normal respirations may occur.) 5.Stimulate the newborn by rubbing the back or flicking the feet. Rationale: Stimulating the baby could result in crying which could aid in increasing respirations 6.Wipe blood and mucus, from the face and body of the newborn. Rationale: Wiping the face stimulates the newborn and clears the secretion that might block the airways. 7.Suction infant’s mouth and nose with a bulb syringe if secretions are present Rationale: Suctioning infant’s mouth and nose is necessary to help establish a clear airway by