risk for infection related to rupture of membranes care plan

Nursing Care Plan for Premature Rupture of the Membranes Patient: Mrs. Anna Care Plan By: Date Initiated: April 21, 2021 Case Study: Mrs. Anna is a 24-year-old pregnant patient that went to the Labor and Delivery triage area complaining, saying "I felt a sudden gush of water and I constantly feel wet". If the infection cannot be prevented, the goal is to prevent the spread of infection between individuals and treat the underlying infection. Preterm PROM is not a contraindication to vaginal delivery. 8. Assist client to learn stress-reducing techniques. No studies are available comparing delivery with expectant management when patients receive evidence-based therapies such as corticosteroids and antibiotics. You may ask patients during history taking when they were last immunized. Susceptible host. (2002). 11. 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. Corticosteroids to help develop the fetuss lungs. -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. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented. Any items you have not completed will be marked incorrect. Goal. After body fluid exposure risk4. Once the fluid has dried on the slide, the physician can check for ferning (arborization) under a low-power microscope. (2011). However, a premature birth also comes with risks. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. Clinical manifestations PROM is marked by amniotic fluid gushing from the vagina. Get useful, helpful and relevant health + wellness information. If labor does not begin or the fetus is judged to be preterm or at risk for infection, explain treatments that are likely to be needed. Involving the patient in the early identification of the presence of an infection can improve the success of treatment once started. Ideally, these treatments allow your pregnancy to progress to at least 34 weeks. Various health problems and conditions can create a favorable environment that would encourage the development of infections. All reflexes are checked and are intact. Some cases of PROM occur without a sudden gush of clear watery fluid from the vagina, so you should always take account of other diagnostic signs such as reduction in size of the abdomen and clearly palpable fetal parts. Desired Outcome: The patient will be able to avoid the development of worsening infection. The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Please follow your facilities guidelines and policies and procedures. A 24 year old pregnant female presents to the L&D triage area complaining of gush of water and constantly feeling wet. Perform a focused assessment on the oropharyngeal region, particularly checking for any collection of abscess. Portal of exit from the reservoir. Figure 1 is an algorithm for management of preterm PROM. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common. PPROM raises the risk for infection. Laboratory and diagnostic study findings. Definition: this is a premature breakage of the membranes such as the amniotic sac that holds the baby in place. According to the patients last menstrual period she is indeed 37 weeks along. Buy on Amazon, Gulanick, M., & Myers, J. L. (2017). Breaks in the integrity of the integument, mucous membranes, soft tissues, or even organs such as the kidneys and lungs can be sites for infections after trauma, invasive procedures, or invasion of pathogens through the bloodstream or lymphatic system. Evidence of fluid pooling in the vagina, or leaking from the cervical os when the patient coughs or when fundal pressure is applied, will help determine PROM. What causes PPROM? 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). 4 0 obj If youre at all unsure whats coming out of your vagina, contact your pregnancy care provider. Long-term tocolysis is not indicated for patients with preterm PROM, although short-term tocolysis may be considered to facilitate maternal transport and the administration of corticosteroids and antibiotics. Preterm PROM typically occurs due to a medical condition or pregnancy complication, but it can result from unknown causes. Some of the most common causes include: The most obvious symptom of your membranes rupturing is feeling a gush of fluid from your vagina. The fetal membranes are so strong that blunt trauma to the abdomen is unlikely to cause PROM. 98.7, O2 Sat 98% on RA, RR 18. Encourage increased fluid intake unless contraindicated (e.g., heart failure, kidney failure). Encourage the use of separate utensils for eating. Generally, there are two options: delivery or expectant management. If this happens after 37 weeks of pregnancy, your pregnancy care provider will deliver your baby. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). A study33 of patients with preterm PROM randomized to home versus hospital management revealed that only 18 percent of patients met criteria for safe home management. The, Sax, H., Allegranzi, B., Uckay, I., Larson, E., Boyce, J., & Pittet, D. (2007). Additionally, WBC differential may show an increase and decrease in certain infections. A retrospective analysis31 of 134 women with preterm PROM at 24 to 32 weeks gestation who received steroids and antibiotics found a nonsignificant trend toward intrauterine inflammation in patients with a latency period longer than one week. Gel or wash hands after coughing or expectorating. It is important to maintain the cleanliness of the affected areas by washing with mild soap and water. 16. 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. Basic and effective defense against the fetus contracting an infection is lost and the risk of ascending intrauterine infection, known as chorioamnionitis, is increased. Use masks respiratory infection is transmitted through contact with contaminated articles or droplets when the patient sneezes or coughs. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Matt Vera, a registered nurse since 2009, leverages his experiences as a former student struggling with complex nursing topics to help aspiring nurses as a full-time writer and editor for Nurseslabs, simplifying the learning process, breaking down complicated subjects, and finding innovative ways to assist students in reaching their full potential as future healthcare providers. Handwashing is the single best way to prevent infection. Ibarra-Coronado, E. G., Pantalen-Martnez, A. M., Velazquz-Moctezuma, J., Prospro-Garca, O., Mndez-Daz, M., Prez-Tapia, M., & Morales-Montor, J. Adequate nutrition enables the body to maintain and rebuild tissues and helps keep the immune system functioning well. Nursing care plans: Diagnoses, interventions, & outcomes. Contact your pregnancy care provider right away if you believe your membranes have ruptured. <> Assist clients in carrying out appropriate skin and oral hygiene. If your pregnancy reaches 37 weeks, complications from premature birth are lower. Once you are finished, click the button below. Educating visitors on the importance of preventing droplet transmission from themselves to others reduces the risk of infection. The human immune system is crucial for survival in a world full of potentially deadly and harmful microbes. Your pregnancy care provider will watch for signs of fetal distress and infection to determine when they should deliver your baby. Manage Settings Provide stoma care through the following steps: Clean the inner part of the stoma; if an inner cannula is used, replace it regularly with a new one. If the rash leads to other skin breakdown which then gets infected, antibiotics is prescribed. Delivering within 24 hours is usually the safest option. Ferning refers to the fern-like pattern of dry amniotic fluid. Perform measures to break the chain of infection and prevent infection. To treat the underlying infection with broad spectrum antibiotics, then switch with the type of antibiotics to which the causative bacteria are sensitive. Buy on Amazon. Desired Outcome: The patient will demonstrate ways to prevent the spread of infection. Previable rupture of membranes also can lead to Potters syndrome, which results in pressure deformities of the limbs and face and pulmonary hypoplasia. %PDF-1.5 Instruct visitors to cover mouth and nose (by using the elbows to cover) during coughing or sneezing; use tissues to contain respiratory secretions with immediate disposal to a no-touch receptacle; perform hand hygiene afterward. Use of corticosteroids between 32 and 34 weeks is controversial. Expectant management is a treatment that delays labor. Other people can spread infections or colds to a susceptible patient (e.g., immunocompromised) through direct contact, contaminated objects, or air currents. 20. The neonate is most likely to be hypothermic. Explain to the client how infections can be transmitted from sharing personal items. Coughing is an effective method to expectorate mucus build up to prevent infection. 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. Use this nursing diagnosis guide to create your risk for infection nursing care plan individualized to your client. If loading fails, click here to try again. Please wait while the activity loads. Place the patient under airborne precaution isolation. Trim the patients fingernails and ensure frequent hand hygiene. Cleveland Clinic is a non-profit academic medical center. Intervention #2. 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). The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders. {`!lC[OW|W9XgVibMaAp\Qx- Desired Outcome: The patient will remain free from infection as evidenced by the absence of fever and clear stoma. Regularly assess the patients stoma and surrounding skin for color, exudates, erythema, and crusting lesions. The formatting isnt always important, and care plan formatting may vary among different nursing schools or medical jobs. The first stage may take about 12 hours to complete and is divided into three phases: latent, active, and transition. Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified. Another method providers may use is a fern test or ferning. Nursing Diagnosis: Risk for Infection related to inflammation of the tonsils. Your pregnancy care provider diagnoses PROM with a sterile speculum exam. The best thing you can do is avoid smoking cigarettes, maintain a healthy pregnancy and attend all of your prenatal exams. Antimicrobials are widely used to treat infections when susceptibility is present. This can be a problem because without amniotic fluid, your chances of infection, premature birth and other complications increase. Methods A prospective cohort study was completed . Determine maternal and fetal status, including estimated gestational age. Patient information: See related handout on preterm premature rupture of membranes, written by the authors of this article. A more recent article on preterm labor is available. Physicians should be reassured that careful visual inspection via a speculum examination is the safest method for determining whether dilation has occurred after preterm PROM. Some babies still get GBS even with testing and treatment. When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the risk of infection is low. Provide surgical masks to visitors who are coughing and provide the rationale to enforce usage. 217: Prelabor Rupture of Membranes. 2. Place the patient in protective isolation if the patient is at high risk of infection.Protective isolation is set when the WBC indicates neutropenia. Begin taking temperature every 2 hours after rupture of membranes and more often as indicated. Encourage the patient to effectively cough out mucus. This is also universally used for those who are at high risk for infection. Encourage hand hygiene and explain the importance of proper handwashing. An upright position and regular position changes prevent the pooling of mucus, therefore preventing infection. In the absence of intra-amniotic infection, the physician should attempt to prolong the pregnancy until 34 weeks gestation. They can then collect a sample of fluid for testing. The diagnosis of PROM requires a thorough history, physical examination, and selected laboratory studies. A common means for infectious diseases to spread is by directly transferring bacteria, viruses, or other germs from one person to another. . American College of Obstetricians and Gynecologists. Rarely, uterine rupture can also occur in women who have not had previous uterine surgery. Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. Studies show that people who deliver within 24 hours of membrane rupture have a lower risk of infection than those who deliver after 24 hours. A fern test is ordered and comes back as positive. PROM may occur if the uterus is over-stretched by malpresentation of the fetus, multiple pregnancy or excess amniotic fluid. Ensure that any articles used are properly disinfected or sterilized before use. When PROM occurs too early, surviving neonates may develop sequelae such as malpresentation, cord compression, oligohydramnios, necrotizing enterocolitis, neurologic impairment, intraventricular hemorrhage, and respiratory distress syndrome. However, if your baby is born before 37 weeks, theyre at higher risk for complications of being born early. Handwashing is the best way to break the chain of infection. Assess immunization status and history. 22. Because corticosteroids are effective at decreasing perinatal morbidity and mortality, all physicians caring for pregnant women should understand the dosing and indications for corticosteroid administration during pregnancy. Long fingernails tend to contain more bacteria. Teach the patient, family, and caregivers, the purpose and proper technique for maintaining isolation. Ivanov, A. V., Bartosch, B., & Isaguliants, M. G. (2017). 4. Risk for Infectionrelated to invasive procedures, recurrent vaginal examination, andamnioticmembrane rupture. 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. Prom may occur if the uterus is over-stretched by malpresentation of the fetus, multiple pregnancy or excess amniotic fluid. 5. As it has helped me alot in my educational field. This information will aid the clinician in targeting at-risk women for intensified obstetric care and entry into prevention programs.Methods: 28,725 deliveries were analyzed over a 16-month time frame (January 1, 1995-April 30, 1996). If your membranes rupture at term (37 weeks of pregnancy), its usually from your amniotic membranes weakening from the pressure of contractions. TANYA M. MEDINA, M.D., AND D. ASHLEY HILL, M.D. Important Disclosure: Please keep in mind that these care plans are listed for, Click to share on Facebook (Opens in new window), Click to share on Twitter (Opens in new window), Click to share on Pinterest (Opens in new window), Click to share on Reddit (Opens in new window), Click to share on LinkedIn (Opens in new window), Click to share on WhatsApp (Opens in new window), Click to share on Pocket (Opens in new window), Click to share on Telegram (Opens in new window), Click to share on Skype (Opens in new window), Most DIFFICULT Patients EVER!! Up to 95% of all births occur within 28 hours of PROM when it happens at term (37 weeks). An example of data being processed may be a unique identifier stored in a cookie. Which of the following increases the risk of placental abruption? Premature rupture of membranes (water breaking) before you reach full term. It is also harmful for pregnant women as it can affect the unborn baby. Physicians caring for patients with preterm PROM before viability may wish to obtain consultation with a perinatologist or neonatologist. (2014). This includes precautions like bed rest, medications and frequent monitoring for infection or fetal distress. These nursing interventions help reduce the risk for infection, including implementing strategies to prevent infection. Choose the letter of the correct answer. The following are the common causes of infection: Nursing Diagnosis: Risk for infection related to Viral illness and immunocompromised status (e.g. Wash hands with antiseptic soap and water for at least 15 seconds, followed by an alcohol-based hand rub. These are the classic signs of infection. Excessive stress predisposes clients to infection. Here are the common causes of infection and factors that place a patient at risk for infection: Inadequate primary defenses (e.g., break in skin integrity, tissue damage). However, its not always a gush. 3.3. Although corticosteroids are not indicated after 34 weeks gestation, physicians should prescribe appropriate antibiotics for group B streptococcus prophylaxis and should consider maternal transport to a facility skilled in caring for premature neonates, if possible. Ensure that the patient finishes the course of antibiotic prescribed by the physician. Monitor temperature, pulse, respiration, and white. ABSTRACT: Intraamniotic infection, also known as chorioamnionitis, is an infection with resultant inflammation of any combination of the amniotic fluid, placenta, fetus, fetal membranes, or decidua. Preterm PROM (or PPROM) is when the amniotic sac breaks before 37 weeks of pregnancy. endobj Preterm PROM complicates approximately 3 percent of pregnancies and leads to one third of preterm births. Patients with amnionitis require broad-spectrum antibiotic therapy, and all patients should receive appropriate intrapartum group B streptococcus prophylaxis, if indicated. 18. Zimmerman, S., GruberBaldini, A. L., Hebel, J. R., Sloane, P. D., & Magaziner, J. Long-term tocolytic therapy in patients with PROM is not recommended; consideration of this should await further research. Insufficient knowledge to avoid exposure to 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. Monitor the patients vital signs and signs of infection. Good luck! Assess for the presence, existence, and history of the common causes of infection (listed above). Limited data are available to help determine whether tocolytic therapy is indicated after preterm PROM. 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. However, sometimes it breaks before labor begins or several weeks before labor begins. She found a passion in the ER and has stayed in this department for 30 years. Registered Nurse, Free Care Plans, Free NCLEX Review, Nurse Salary, and much more. Delivery before 32 weeks gestation may lead to severe neonatal morbidity and mortality. 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. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but they are not having contractions. Elevated temperature.Fever is often the first sign of an infection. Fever during labor. 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. Very low WBC count may indicate a severe risk for infection. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. The major symptom is fever. Assess for the presence of local infectious processes in the skin or mucous membranes. Physicians should administer a course of corticosteroids and antibiotics and perform an assessment of fetal well-being by fetal monitoring or ultrasonography. Premature rupture of membranes (PROM) is when you leak amniotic fluid before labor begins. Preterm premature rupture of the membranes (PPROM) is a pregnancy complication. This means your uterus may be contracting, and your cervix may be thinning (effacing) and dilating (opening) without you feeling anything. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client CareIdentify interventions to plan, individualize, and document care for more than 800 diseases and disorders.

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