CASE: 32-week premature rupture of membranes caused by oropharyngeal microbiota
ASSESSMENT NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Objective Data: Risk for fetal The vaginal- Goal: Review the lifestyle This can give the After the nurse-
• G3P2 32 weeks infection related rectal and • Until the ideal and habits of the nurse the idea on patient
and 5 days AOG to preterm endocervical time for delivery, mother for possible what activities of interaction, the
• BP: 126/79 premature culture revealed the mother will risk factors of the mother will patient is able to:
mmHg; temp: rupture of the presence of be able to complications. she need further • Understand
36.5 C membranes several maintain the teaching. what she can
• Sterile speculum secondary to the pathogenic fetus free from and cannot do
exam: release of presence of microorganisms infection. Provide health Health teaching to limit the
clear amniotic oropharyngeal which are Long-term teachings that informs the spread of
fluid microbiota normally found in objective: promote limiting the mother of what infection.
• Transvaginal utz: the oropharynx. • After days of spread of infection she can do to • Demonstrate
closed In the case nurse-patient and reduce the help reduce the measures of
multiparous cervix report, it was interaction, the complications like risk of infecting reducing the
with a length of found that the patient will be proper hygiene. her baby. risk of further
22mm presence of able to complications
• Abdominal utz: these demonstrate Encourage rest Physical such as
fetus in cephalic microorganism behaviors of periods and exhaustion getting rest
position with caused the limiting the risk relaxation. makes the patient periods and
cardiac activity, PPROM. Given of infection. more vulnerable relaxation and
and active fetal the decreased Short-term of precipitating observing
movements, a integrity of body objectives: the infection. proper
normal inserted defenses due to • Within 8 hours hygiene.
placenta on the the rupture of of the shift, the Instruct the mother Occurrence of • Know what
upper anterior amniotic patient will be to inform the nurse signs of infection signs to look
side, and normal membranes, able to: immediately if any indicates that the for that
amount of there is an o Verbalize signs of infection or abundance of indicates
amniotic fluid increased risk for understanding unusual fetal activity pathogen may immediate
• Cardiotocographic fetal infection. of causative occur such as fever, have worsen. medical
record: good fetal and risk dysuria, foul- Unusual fetal intervention.
reactivity with factors smelling urine and activity indicates
absence of o Identify decreased/increased the presence of
measures that fetal activity. fetal
complications.
uterine can help her Collaborate with This helps
contractions reduce the risk other members of modification of
• Urine culture: (-) of infection the health care team care provided by
• Vaginal-rectal o Demonstrate with the responses the health care
culture: (+) group behaviors that and progress of the team.
B streptococcus limit the case of the patient.
• Endocervical spread of
culture: (+) infection and Administer Betamethasone
Staphylococcus reduce the betamethasone, as is used in lung
aureus, (+) occurrence of ordered. maturation
serogroup B complications regimen.
Neisseria
meningitides, (+) Administer Antibiotics serve
Haemophilus prophylactic as prophylaxis or
influenza antibiotics, as prevention of
Subjective Data: ordered. occurrence or
• Patient reported worsening of the
vaginal discharge infection.
of clear fluid with
no uterine
contractions or
bleeding
References:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurses pocket guide: diagnoses, prioritized interventions, and rationales (11th ed.).
Philadelphia: F.A. Davis.
Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & child health nursing: Care of the childbearing & childrearing family (8th ed., Vol. 1).
Philadelphia: Wolters Kluwer.
