Problem
Labor Case Scenario:
You are the staff nurse working in labor and delivery at a nearby local hospital. Analyn, 29 years old, 39 weeks AOG, gravid for the second time, comes to the admitting unit having contractions and feeling somewhat uncomfortable.
On admission, she appears restless, has a dry mouth, and has a heartbeat of 101 beats per minute. You take the assessment and assisted her to change her street clothes into a patient's gown and ask her questions to determine your next action. Upon seeing the facial expression noted on her face and the initial assessment made, you then inform Dr. Ong the Obstetrics about Analyn's status. Dr. Ong then informed Analyn that she needs to check and will do an internal examination to verify the true signs of labor. The OB then ordered to prepare the patient for vaginal examination. The staff assigned prepared the patient first by telling her to empty her bladder first before the start of the procedure.
A few minutes later, prepping, and perineal flushing was done for the physician to initiate the internal examination. The physician stated that Analyn is 80% effaced and 5 cm dilated, with an intact bulging bag of water. The patient has regular contractions 4 to 5 minutes apart and lasting 40 seconds.
While the patient was being transferred to the labor area for contraction and FHT monitoring, the staff nurse safely secures the patient on her bed and instructed the patient that she will be attached to an Electronic Fetal machine (EFM) to determine the contractions, fetal heart tone, and fetal movement. Making ready for the EFM attachment, the nurse begins to do Leopold's maneuver to identify the fetal presentation and position and to locate the fetal back for placement of the diaphragm of the stethoscope.
The fetal heart tone (FHT) ranges from 133 to 155 beats/minute. An hour had passed, the patient called the attention of the nurse, stating "something came out that looked like water, but I'm not sure if it was urine". The nurse then inspects the perineum to determine to what extent the process takes place, and at the same time assures that fetal structure was not yet seen in the vaginal opening. A few minutes later, Dr. Ong had her IE again to confirm that the bag of water has ruptured, which reveals a light yellowish color with little white specks on it. And has a relevant change with the cervical dilatation to 8cms now, with a thinner lining of the cervix. While transferring the patient to the delivery table, Analyn is having frequent, strong palpation contractions that are extremely uncomfortable. She is trembling, complaining of nausea and an uncontrollable urge to push. A few minutes later she went in normal labor and delivered a healthy single baby boy with an 8 Apgar score at birth and 9 Apgar score at 5 min. She sustained a second-degree perineal laceration which was repaired, and sutures were applied. Oxytocin (Pitocin) 10 IU 1 ampoule incorporated to present IVF of D5LR@1L and regulated at 120 mL/hr.
Task
1) List all the possible Nursing Diagnosis of this case scenario
2) List Nursing Intervention with Rationale