Pt.

Name: Mother Agon

23y/o

G2 P0 A1 L0

Dr. Dy

October 26, 2016

Assessment:

Subjective cues

: Ingon sa akong doctor, magpa admit daw ko ky hatagan daw ko ug steroid para
sa akong baby

Objective cues:

With O2 inhalation via nasal cannula @ 3 Lpm

With IVF of Plain LR @ Left metacarpal vein at KVO rate @ 800cc level
Hooked to EFM for baseline data
VS taken with BP ranges 130/90-140/100; HR 75-80; RR 17-23
FHT checked strong and regular @ 140bpm
Moderate uterine contraction with 40-60 sec duration with 7-8 min
interval
Voiding freely
On Diabetic diet
On complete bed rest
Diagnosed with DM II in 2014
G2P0A1L0
AOG 36 weeks and 1 day
EDD: November 20, 2016
Good grooming noted

Need: Health Perception Health Management Pattern

Nursing Diagnosis: Risk for ( Maternal and Fetal) Injury related to preterm labor and
birth

Objective of Care:

That within my 8-hour shift, Mother Agon will

a. Learn the symptoms of preterm labor and be able to assess herself and her
need for intervention
b. Maintain her pregnancy for at least 37 completed weeks
c. Not to experience preterm labor
 d. Maintain BP within normal limits which is less than 140/90
e. Maintain blood sugar within normal limits

Nursing Interventions:

Independent:

1. Establish rapport with the patient

Rationale:

2. Assess for maternal conditions that would contraindicate steroid therapy to

facilitate fetal lung maturity.
Rationale:
In PIH and chorioamnionitis, steroid therapy may aggravate hypertension and
mask signs of infection. Steroids may increase serum glucose levels in the
patient with diabetes. Drug will not be effective if unable to delay birth for at
least 48 hours.

3. Assess FHR; note presence of uterine activity or cervical changes. Prepare to

possible preterm delivery
Rationale: Tocolytics can increase FHR. Delivery may be extremely rapid with
small infant if persistent uterine contractions are unresponsive to tocolytics,
or if cervical changes continue
.
4. Provide information about the actions and side effects of the drug therapy
Rationale: Steroid therapy: most effective for increasing lung surfactant when
the fetus is between 30 and 32 weeks gestation.

5. Monitor for signs of PIH (edema, hypertension, proteinuria).

Rationale: About 12-13% of diabetic individuals develop hypertensive
disorders owing to cardiovascular changes associated with diabetes. These
disorders negatively affect placental perfusion and fetal status

6. Provide information about possible effects of diabetes on fetal growth and

development
Rationale: Helps client to make informed decisions about managing regimen
and may increase cooperation.

7. Monitor blood sugar and provide information and reinforce procedure for
home blood glucose monitoring and diabetic management.
Rationale: Decreased fetal or newborn mortality and morbidity complications
and congenital anomalies are associated with optimal FBS levels between 70
to 96 mg/dL, and 2-hr postprandial glucose level of less than 120 mg/dL.
Frequent monitoring is important to maintain this tight range and to reduce
an incidence of fetal hypoglycemia or hyperglycemia

Dependent/Collaborative:
1. Administer Dextamethasone as ordered
Rationale: Dexamethasone is a synthetic cortisol that can accelerate fetal
lung maturity by stimulating surfactant production and thereby preventing or
decreasing the severity of respiratory distress syndrome
2. Administer Humulin IM as ordered
Rationale: