Some conditions associated with risk for infection are: Chronic illness Immunosuppression Invasive procedures Decrease in hemoglobin Leukopenia Open wounds Malnutrition Rupture of amniotic membranes Antibiotic therapy Altered pH of mucous secretions Nursing Assessment for Risk for Infection 1. endobj The human immune system is crucial for survival in a world full of potentially deadly and harmful microbes. However, certain conditions or factors may increase the chances of a prolapse occurring. Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Treatment varies depending on gestational age and includes consideration of delivery when rupture of membranes occurs at or after 34 weeks gestation. Which of the following would the nurse Sandra most likely expect to find when assessing a pregnant client with abruption placenta? Speculum examination is preferred. However, an infection can occur when the body is not strong enough to fight off the infection. (2020). Client will maintain or restore defenses. Portal of exit from the reservoir. 4. Medical-surgical nursing: Concepts for interprofessional collaborative care. The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. In unusual cases in which the patients history suggests preterm PROM, but physical examination findings fail to confirm the diagnosis, ultrasonography may be helpful. The latent period, which is the time from membrane rupture until delivery, generally is inversely proportional to the gestational age at which PROM occurs. Advise all patients with rupture of membranes that they are at increased risk of infection and need hospital care promptly. Assess for the presence of local infectious processes in the skin or mucous membranes. stream Monitor temperature, pulse, respiration, and white. After body fluid exposure risk4. Ensure that the patient finishes the course of antibiotic prescribed by the physician. Methods A prospective cohort study was completed . Encourage the use of separate utensils for eating. Rates are as follows: 5. Pt denies any uterus tenderness andthe patient states she felt the babys last movement about an hour ago. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, (https://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000233/PS-Prelabor-rupture-of-membranes-FINAL-22-MAR-18.pdf), (https://www.ncbi.nlm.nih.gov/books/NBK532888/). You also have a higher chance of having your baby born early. Use this nursing diagnosis guide to create your risk for infection nursing care plan individualized to your client. Your provider will monitor you closely for signs of infection. The most important part of the care plan is the content, as that is the foundation on which you will base your care. -The nurse will assess the patient from any signs and symptoms of infection every 4 hours while hospitalized.-The nurse will follow sterile procedure during any vaginal exams. 21. W]1}IM%2 \Xn+#DA #`K- b:/W_+y38'0R"ls}Hy6h_[~)W^/*&V\ackh6#pn*y@lr@lx C"%Q0-z8B^b>(Q*1|7ex&HfK2me_z#A)ZIdha Preterm premature rupture of the membranes (PPROM) is a pregnancy complication. Limit visitors.Restricting visitation reduces the transmission of pathogens. A., & Taylor, R. (2001). Previable rupture of membranes also can lead to Potters syndrome, which results in pressure deformities of the limbs and face and pulmonary hypoplasia. The first stage may take about 12 hours to complete and is divided into three phases: latent, active, and transition. This is a rare but serious complication in which the uterus tears along the scar line from a prior C-section or major uterine surgery. 3. Promote proper positioning or regular position changes. Appearance of urine.Cloudy, turbid, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection. Corticosteroids can reduce many neonatal complications, particularly intraventricular hemorrhage and respiratory distress syndrome, and antibiotics are effective for increasing the latency period. To maintain patient safety and reduce the risk for cross contamination. Buy on Amazon, Gulanick, M., & Myers, J. L. (2017). Please follow your facilities guidelines and policies and procedures. Obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic streptococci, an organism that increases the risk to the fetus. Cover mouth when coughing or sneezing. 98.7, O2 Sat 98% on RA, RR 18. Use masks respiratory infection is transmitted through contact with contaminated articles or droplets when the patient sneezes or coughs. (2002). Premature rupture of membranes (PROM) is the rupture of the fetal membranes before the onset of labor. It is important to note that vaginal blood may obscure the presence of ferns, and that cervical mucus can result in a false-positive result if the external cervical os has been swabbed. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. Educate the patient on the need for staff to use personal protective equipment when looking after them. If loading fails, click here to try again. Unlike when you pee, you wont be able to hold it in. A meta-analysis2 showed that patients receiving antibiotics after preterm PROM, compared with those not receiving antibiotics experienced reduced postpartum endometritis, chorioamnionitis, neonatal sepsis, neonatal pneumonia, and intraventricular hemorrhage. Give information regarding vaccination status. This means your uterus may be contracting, and your cervix may be thinning (effacing) and dilating (opening) without you feeling anything. They can then collect a sample of fluid for testing. Teach the patient, family, and caregivers, the purpose and proper technique for maintaining isolation. It also increases your chance of having your baby too early. Nursing Diagnosis: Risk for Infection related to inflammation of the tonsils. This reduces or eliminates germs. TANYA M. MEDINA, M.D., AND D. ASHLEY HILL, M.D. Preterm premature rupture of membranes is the rupture of membranes during pregnancy before 37 weeks gestation. Isolate the patient in his/her room ideally during the first 48 hours since the appearance of blisters. Consider readmission to the hospital for these patients after 24 weeks gestation to allow for close fetal and maternal monitoring. Your provider may induce labor with medications or allow your labor to progress on its own. My five moments for hand hygiene: a user-centred design approach to understand, train, monitor and report hand hygiene. Preterm PROM complicates approximately 3 percent of pregnancies and leads to one third of preterm births. Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover, administration, and social factors, Inadequate primary defenses (e.g., break in. This can transpire via contact, airborne, sexual contact, or sharing of IV drug paraphernalia. Educating the patient about the disease can raise confidence and understanding of the importance of sticking to the guidelines. Once the fluid has dried on the slide, the physician can check for ferning (arborization) under a low-power microscope. American College of Obstetricians and Gynecologists. Handwashing is the best way to break the chain of infection. Buy on Amazon. Excessive stress predisposes clients to infection. Encourage the patient to effectively cough out mucus. Tocolytic therapy may prolong the latent period for a short time but do not appear to improve neonatal outcomes.26 In the absence of data, it is not unreasonable to administer a short course of tocolysis after preterm PROM to allow initiation of antibiotics, corticosteroid administration, and maternal transport,27 although this is controversial. Mother states / shows are free of any signs of infection. Patients with preterm premature rupture of membranes between 32-36 weeks have been studied and concluded that expedited delivery is generally the best outcome because the risk of infection outweighs letting the baby stay in utero, once the medications are administered between 1-2 days, the likelihood of survival is more favorable (Mercer, 2008). GBS infection in a previous baby. Preventing infection is a vital role of all healthcare professionals. The majority of patients will deliver within one week when preterm PROM occurs before 24 weeks gestation, with an average latency period of six days.15 Many infants who are delivered after previable rupture of the fetal membranes suffer from numerous long-term problems including chronic lung disease, developmental and neurologic abnormalities, hydrocephalus, and cerebral palsy. The nurse is reviewing orders on a patient admitted for preterm premature rupture of membranes. 6. Fetal Heart Rate is present with a rate 130 bpm and the patient states she felt the babys last movement about an hour ago. endobj Preterm PROM complicates approximately 3 percent of pregnancies and leads to one third of preterm births.1It increases the risk of prematurity and leads to a number of other perinatal and neonatal complications, including a 1 to 2 percent risk of fetal death.2 Physicians caring for pregnant patients should be versed in the management of preterm PROM because rapid diagnosis and appropriate management can result in improved outcomes. St. Louis, MO: Elsevier. We strive for 100% accuracy, but nursing procedures and state laws are constantly changing. Management: Preterm PROM typically occurs due to a medical condition or pregnancy complication, but it can result from unknown causes. The consent submitted will only be used for data processing originating from this website. As an Amazon Associate I earn from qualifying purchases. Assess for the presence, existence, and history of the common causes of infection (listed above). The neonate is most likely to be hypothermic. Corticosteroid administration may lead to an elevated leukocyte count if given within five to seven days of PROM. Expectant management is a treatment that delays labor. Nursing Diagnosis: Risk for infection related to the presence of artificial airway (tracheostomy). Specific nursing interventions will depend on the nature and severity of the risk. Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset of labor at or beyond 37 weeks' gestation. When preterm PROM is suspected, it is important to avoid performing a digital cervical examination; such examinations have been shown to increase morbidity and mortality.14,15 Digital cervical examinations also cause an average nine-day decrease in the latent period.16 Shortening of the latent period may lead to increased infectious morbidity and sequelae from preterm labor. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. -The nurse will educate the patient on the importance of refraining from any type of sexual intercourse and tampons usage until after pregnancy. (2015). She has worked in Medical-Surgical, Telemetry, ICU and the ER. Client will be free of infection as evidenced by: Maternal temperature remains WNL during labor and fetal heart rate remains between 120 and 160. St. Louis, MO: Elsevier. Signs and symptoms of infection vary according to the body area involved. Compromised circulation (e.g., obesity, lymphedema, peripheral vascular disease). If the diagnosis of an intrauterine infection is suspected but not established, amniocentesis can be performed to check for a decreased glucose level or a positive Gram stain and differential count can be performed.6 For patients who reach 32 to 33 weeks gestation, amniocentesis for fetal lung maturity and delivery after documentation of pulmonary maturity, evidence of intra-amniotic infection, or at 34 weeks gestation should be considered. There appears to be no single etiology of preterm PROM. Encourage sleep and rest. Assess, monitor, and record the patients vital signs. Complications from premature birth include breathing difficulties, low body temperature and poor growth. A blue result means the fluid on the paper has a pH of greater than 6.0 and is likely amniotic fluid. . If your pregnancy is fewer than 37 weeks and your membranes rupture, your pregnancy care provider will decide if delivery is necessary or if they can delay labor. Infections occur when the natural defense mechanisms of an individual are inadequate to protect them. One of the most common complications of preterm PROM is early delivery. This is the final step in the chain of infection. 3.3. When there is PROM the risk of serious infection is increased (1% versus 0.5% for women with intact membranes). <> In older patients, the infection may be present without an increased WBC count. Secure the tracheostomy tube. Inform the client, if the fetus is at term, that the chances of spontaneous labor beginning are excellent; encourage the client and partner to prepare themselves for labor and birth. After touching the patients surroundings. Physicians should ask whether the patient is contracting, bleeding vaginally, has had intercourse recently, or has a fever. Promote nail care by keeping the client and the nurses fingernails short and clean. Mode of transmission. Generally, there are two options: delivery or expectant management. -The patient will verbalized the importance of refraining from sexual intercourse of any typeorusage of tampons until after pregnancy. NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023The definitive guide to nursing diagnoses is reviewed and approved by NANDA International. Its important to note that if you already have an infection at the time of rupture or develop one afterward, delivery is necessary. It surrounds the fetus during pregnancy. Tonsillitis may cause blockage of airways, which may lead to respiratory distress. Labor or waters breaking (rupture of membranes) before 37 weeks (preterm) Rupture of membranes 18 hours or longer before delivery of a full-term pregnancy . All-in-One Nursing Care Planning Resource E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental HealthIncludes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Occasionally, patients present with conflicting history and physical examination findings (e.g., a history highly suspicious for ruptured membranes with a normal fern test but positive nitrazine test). A separate swab should be used to obtain fluid from the posterior fornix or vaginal sidewalls. Compromised host defenses (e.g., radiation therapy, organ transplant, medication therapy). Proper hygiene promotes wellness and prevents further infection. 10. Its normal for the membranes to break by themselves, but this usually happens after labor starts. As described above, corticosteroids and antibiotics are beneficial when administered to patients with preterm PROM, but no studies of these therapies combined with tocolysis are available. Fetal Heart Rate is present with a rate 130 bpm. Nursing Diagnosis: Risk for infection related to loss of protective barrier as evidence by positive ferns test. Early recognition of infection to allow for prompt treatment. 17. Monitor white blood cell (WBC) count. Numerous risk factors are associated with preterm PROM. PPROM accounts for 25% of all cases of premature rupture of the membranes and is responsible for 30%-40% of all preterm deliveries. Delivering within 24 hours is usually the safest option. Antibiotics to prevent infection and prolong the pregnancy. There are two purposes in isolating a person with tuberculosis: protect the patient and protect others. Some physicians are concerned that not performing a digital examination may lead to the misdiagnosis of advanced preterm labor with imminent delivery, which has important implications for patients who require transfer to a tertiary care center; however, a prospective comparison17 found that the difference between digital and speculum examinations was not clinically significant. An increasing WBC count indicates the bodys efforts to combat pathogens. Clostridium Difficile C. Diff Infection and Prevention, Hydronephrosis Nursing Diagnosis and Care Plan, Self Care Deficit Nursing Diagnosis and Care Plan, Erythema redness on the affected body part, region, or area, Warmth and/or tenderness on the affected body part, region, or area. Long-term tocolytic therapy in patients with PROM is not recommended; consideration of this should await further research. Maternal infection may occur during labor (chorioamnionitis) or after birth (postpartum endometritis), and prolonged rupture of membranes and multiple vaginal examinations are known risk factors for the development of maternal and neonatal infection. Knowledge of ways to reduce or eliminate germs reduces the likelihood of transmission. Teach the patient how to perform proper hand hygiene. In addition to the above causes, other risk factors include: -The nurse will verbalize and demonstrate proper hand hygiene techniques to the patient.

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