risk for infection related to rupture of membranes care plan risk for infection related to rupture of membranes care plan
1 It increases the risk of prematurity and leads to a number of other perinatal and. No edema is present and UA comes back as negative. These include: The biggest concern with PROM is premature birth. Insufficient knowledge to avoid exposure to pathogens. Desired Outcome: The patient will remain free from infection as evidenced by the absence of fever and clear stoma. Surgery can be the treatment of choice if the tonsillitis is causing difficult to manage complications such as apnea, swallowing difficulty, and abscess formation. Preterm PROM complicates approximately 3 percent of pregnancies and leads to one third of preterm births. The, Sax, H., Allegranzi, B., Uckay, I., Larson, E., Boyce, J., & Pittet, D. (2007). Explain to the client how infections can be transmitted from sharing personal items. Without the protection of amniotic fluid, the pregnancy is at risk for other complications, including: Your pregnancy care provider weighs the risks of premature birth against the risks of infection and other complications before deciding when its best to deliver. <> Black patients are at increased risk of preterm PROM compared with white patients.11 Other patients at higher risk include those who have lower socioeconomic status, are smokers, have a history of sexually transmitted infections, have had a previous preterm delivery, have vaginal bleeding, or have uterine distension (e.g., polyhydramnios, multifetal pregnancy).5 Procedures that may result in preterm PROM include cerclage and amniocentesis. 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 . Explain the need to self-isolate for 14 days if any covid-19 symptoms arise, or if patient tested positive. Interrupting the chain of infection (see image above) is an effective way to prevent the spread of infection. Another study29 of 430 women with preterm PROM revealed that there was no improvement in major or minor neonatal morbidity after 34 weeks gestation. Proper hygiene promotes wellness and prevents further infection. Monitor maternal temperature every 4 hours. Cough or expectorate onto a tissue and dispose of after use. Choose the letter of the correct answer. 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). Treatment can be started as soon as an infection is identified. Promote nail care by keeping the client and the nurses fingernails short and clean. No edema is present and UA comes back as negative. 7. You may be at higher risk for PPROM or PROM if you have or develop any conditions that weaken the chorioamniotic membrane (the outer layer of the amniotic sac). 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. 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. Teach the patient, family, and caregivers, the purpose and proper technique for maintaining isolation. Other people can spread infections or colds to a susceptible patient (e.g., immunocompromised) through direct contact, contaminated objects, or air currents. Wash hands or perform hand hygiene before having contact with the patient. Goal. This is the way the pathogen transfers from the reservoir to the host. Bed rest at home before viability (i.e., approximately 24 weeks gestation) may be acceptable for patients without evidence of infection or active labor, although they must receive precise education about symptoms of infection and preterm labor, and physicians should consider consultation with experts familiar with home management of preterm PROM. The infection occurs in the lining of the uterus (the endometrium) or the upper genital tract. She denies having any labor contractions. 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!! Manual suctioning of the secretions may be necessary to avoid pooling of mucus in the airway if the patient is unable to independently cough it out. Subjective Data: A 24 year old pregnant female presents to the L&D triage area complaining of "gush of water" and constantly feeling wet. -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. {`!lC[OW|W9XgVibMaAp\Qx- Teach the patient how to perform proper hand hygiene. The neonate is most likely to be hypothermic. Ferning refers to the fern-like pattern of dry amniotic fluid. Maternal fever, fetal tachycardia, and malodorous discharge may indicate infection. The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Reime, M. H., Harris, A., Aksnes, J., & Mikkelsen, J. Ensure that the patient finishes the course of antibiotic prescribed by the physician. If you leave this page, your progress will be lost. Risk for infection is a NANDA nursing diagnosis that involves the alteration or disturbance in the body's inflammatory response, which allows microorganisms to invade the body and cause infection. Patients often report a sudden gush of fluid with continued leakage. Preventing infection is a vital role of all healthcare professionals. The regimen studied by the National Institute of Child Health and Human Development trial25 uses an intravenous combination of 2 grams of ampicillin and 250 mg of erythromycin every six hours for 48 hours, followed by 250 mg of amoxicillin and 333 mg of erythromycin every eight hours for five days. Speculum examination is preferred. <> Next steps. Keep the stoma clean and dry. Risk for Infectionrelated to invasive procedures, recurrent vaginal examination, andamnioticmembrane rupture. Premature rupture of membranes, or PROM, is when your water breaks before labor starts. 11. The presence of ferning indicates PROM. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance. 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. -The nurse will educate the patient on 6 signs and symptoms of infection the patient should watch out for. 12. All images, articles, text, videos, and other content found on this website are protected by copyright law and are the intellectual property of RegisteredNurseRN.com or their respective owners. Physicians should ask whether the patient is contracting, bleeding vaginally, has had intercourse recently, or has a fever. See permissionsforcopyrightquestions and/or permission requests. Risk for infection is a NANDA nursing diagnosis that involves the alteration or disturbance in the bodys inflammatory response, which allows microorganisms to invade the body and cause infection. Please follow your facilities guidelines and policies and procedures. If taking antibiotics, instruct the patient to take the full course of antibiotics even if symptoms improve or disappear.Antibiotics work best when a constant blood level is maintained when medications are taken as prescribed. (2014). Determine maternal and fetal status, including estimated gestational age. Client will remain free of infection, as evidenced by normal vital signs and absence of signs and symptoms of infection. This risk is compared with the risks of prematurity. Proper application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection. In mothers diagnosed with PPROM without evidence . Antibiotic may protect against the development of chorioamnionitis in women at risk. (2011). Magnesium sulfate to help the fetuss brain. This depends on your condition and how many weeks pregnant you are at the time of rupture. Observe and report if an older client has a low-grade fever or new onset of confusion. Typically, your membranes rupture after labor (or contractions) begins. 8. When the membranes break (rupture), the amniotic fluid surrounding the fetus starts to leak or gush out your vagina. It is also harmful for pregnant women as it can affect the unborn baby. The fetal membranes are so strong that blunt trauma to the abdomen is unlikely to cause PROM. Inadequate primary defenses such as broken skin. 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. Chorioamnionitis is an infection of the placenta and the amniotic fluid. It may be helpful to put a white paper towel on the fluid. cancer, ongoing chemotherapy, diabetes, etc.). Another common medical intervention is called immunization. History of previous genital herpes with unknown culture result and infant delivered vaginally or by C-section after rupture of membranes. In addition to the above causes, other risk factors include: If membranes rupture at term, but she has no sign of imminent delivery, infection or fetal distress, have patient go to hospital in anticipation of delivery. Organs and tissues involved in the immune system include the thymus, bone marrow, lymph nodes, spleen, appendix, tonsils, and Peyers patches (in the small intestine). Delivering within 24 hours is usually the safest option. Also, having inadequate resources, lack of knowledge, and being malnourished place an individual at high risk of developing an infection. Prematurity, congenital defects, and maternal complications such as premature rupture of membranes (PROM) or . You have not finished your quiz. We and our partners use cookies to Store and/or access information on a device. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. 2. Choriodecidual infection or inflammation may cause preterm PROM.12 A decrease in the collagen content of the membranes has been suggested to predispose patients to preterm PROM.13 It is likely that multiple factors predispose certain patients to preterm PROM. Patient will demonstrate a meticulous hand washing technique. Nursing Dx: Risk for infection related to prolonged rupture of membranes. Long-term tocolytic therapy in patients with PROM is not recommended; consideration of this should await further research. After touching the patients surroundings. Vital signs are important markers of infection. %PDF-1.5 Appropriate evaluation and management are important for improving neonatal outcomes. Premature birth is when your baby is born before 37 weeks of pregnancy. When stasis occurs, microbial infection of the respiratory tract occurs and may lead to pneumonia. Buy on Amazon. If your membranes rupture at term (37 weeks of pregnancy), its usually from your amniotic membranes weakening from the pressure of contractions. Promote proper positioning or regular position changes. When the patient touches other people or objects with infected hands, the infection will likely spread. (2020). The newborn's immune system is immature and can not yet protect against pathogens - at least for the first few months. Intervention #1. Assess and monitor nutritional status, weight, history of weight loss, and serum albumin.Patients with inadequate nutrition may be anergic or unable to muster a cellular immune response to pathogens, making them susceptible to infection. This involves your provider inserting a speculum into your vagina. We do not endorse non-Cleveland Clinic products or services. Methods A prospective cohort study was completed . The rash may cause mild itching, but it is advisable to prevent the child from scratching the affected areas to prevent worsening and spread of the infection. Expectant management is a treatment that delays labor. Maintain strict asepsis for dressing changes, wound care, intravenous therapy, and catheter handling. Fetal Heart Rate is present with a rate 130 bpm. Hypoxia and asphyxia of the woman in labour is a common complication of prolonged PROM. Using tobacco is a risk factor for developing PROM (as well as other pregnancy complications). Premature Rupture of Membranes (PROM) Nursing Care Plan & Management, Maternal and Child Health Nursing (NCLEX Exams), Medical and Surgical Nursing (NCLEX Exams), Pharmacology and Drug Calculation (NCLEX Exams), Ectopic Pregnancy Nursing Care Management, Large-for-Gestational Age (LGA) Newborn Nursing Care Plan & Management, Early Postpartum Hemorrhage Nursing Care Plan & Management, Rheumatic Fever Nursing Care Plan & Management, Hyperemesis Gravidarum Nursing Care Plan & Management, Perform initial vaginal examination, when the contraction. The patient can make an informed choice about getting vaccinated when information is available. % Saunders comprehensive review for the NCLEX-RN examination. Avoid talking, coughing, or sneezing over open wounds or sterile fields. A pathogen can be a bacterium, virus, fungus, parasite, or any other microorganisms. The risk of chorioamnionitis with term PROM has been reported to be less than 10% and to increase to up to 40% for latency periods exceeding 24 hours (Seaward, P.G et al, 1997) Chest imaging appearance of COVID-19 infection. During the speculum examination, a DNA probe or cervical culture for chlamydia and gonorrhea should be performed, because women with these infections are seven times more likely to have PROM.19 After the speculum is removed, a vaginal and perianal (or anal) swab for group B streptococcus culture should be obtained. For instance, shorter sleep durations are associated with a rise in suffering from the common cold. -The nurse will verbalize and demonstrate proper hand hygiene techniques to the patient. Antibiotics to prevent infection and prolong the pregnancy. This content is owned by the AAFP. If its yellow or has an odor, its likely urine. Yes, the fetus can survive if your water breaks too soon. By accessing any content on this site or its related media channels, you agree never to hold us liable for damages, harm, loss, or misinformation. Obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic streptococci, an organism that increases the risk to the fetus. Educate the patient with easy-to-understand words on the pathology of tuberculosis. Continue with Recommended Cookies. Encourage increased fluid intake unless contraindicated (e.g., heart failure, kidney failure). Allowing a pregnancy to continue after the membranes rupture increases your chances of infection and other complications. Your pregnancy care provider diagnoses PROM with a sterile speculum exam. Nursing diagnoses handbook: An evidence-based guide to planning care. Varicella infection is generally treated using antiviral therapy. Regular stoma care prevents infection and helps maintain a clear, patent airway. Encourage sleep and rest. No studies are available comparing delivery with expectant management when patients receive evidence-based therapies such as corticosteroids and antibiotics. Various health problems and conditions can create a favorable environment that would encourage the development of infections. Varicella infection is an infectious/ communicable skin disease to people who have not had chickenpox before. Initiate specific precautions for suspected agents as determined by CDC protocol. endobj Nitrazine paper will turn blue when the pH is above 6.0; however, the presence of contaminating substances (e.g., blood, semen, alkaline antiseptics) also can cause nitrazine paper to turn blue, giving a false-positive result. Aseptic technique decreases the chances of transmitting or spreading pathogens to or between patients. Amniotic fluid protects the fetus from infection, cushions its movements and helps develop its muscles and bones. If your membranes rupture too soon, the fetus is at risk for premature birth or infection. Tonsillitis can lead to peritonsillar abscess. Your healthcare provider may call it prelabor rupture of membranes. Prelabor is the newer, preferable term because it describes membrane rupture before labor starts prelabor rupture without implying prematurity. For pregnant clients, assess the intactness of amniotic membranes. Investigate the use of medications or treatment modalities that may cause immunosuppression.Antineoplastic agents, corticosteroids, and so on can suppress immune function. Registered Nurse, Free Care Plans, Free NCLEX Review, Nurse Salary, and much more. Corticosteroid administration may lead to an elevated leukocyte count if given within five to seven days of PROM. An upright position and regular position changes prevent the pooling of mucus, therefore preventing infection. The following are the common causes of infection: Nursing Diagnosis: Risk for infection related to Viral illness and immunocompromised status (e.g. St. Louis, MO: Elsevier. Postpartum endometritis is an infection that some women develop after giving birth. Once the sac breaks, you have an increased risk for infection. According to the patients last menstrual period she is indeed 37 weeks along. The following methods help break the chain of infection and prevent conditions that may be suitable for microbial growth: 7. Adequate sleep is an essential modulator of immune responses. Ideally, these treatments allow your pregnancy to progress to at least 34 weeks. 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. What are nursing care plans? 19. Plain soap is good at reducing bacterial counts, but antimicrobial soap is better, and alcohol-based hand rubs are the best. 2 0 obj As an Amazon Associate I earn from qualifying purchases. Low-grade temperature elevation that appears in older clients must be reported as it could potentially be an infection. Monitor temperature, pulse, respiration, and white. Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset of labor at or beyond 37 weeks' gestation. They can then collect a sample of fluid for testing. Your water breaking isnt something you can control. 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. To assess for the evidence of ongoing infection. Additionally, WBC differential may show an increase and decrease in certain infections. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Monitor white blood cell (WBC) count. Insufficient knowledge to avoid exposure to pathogens. The infection can cause pus production which then collects behind the tonsils. Your membranes are a fluid-filled sac (also called the amniotic sac) containing amniotic fluid. Consultation with a neonatologist and physician experienced in the management of preterm PROM may be beneficial. Compromised host defenses (e.g., cancer, immunosuppression, AIDS, diabetes mellitus ). Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. Cloudy amniotic fluid, with strong odor A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP) suite. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Adequate nutrition enables the body to maintain and rebuild tissues and helps keep the immune system functioning well. Specific nursing interventions will depend on the nature and severity of the risk. Encourage spitting onto a tissue and discarding the tissues immediately. You also have a higher chance of having your baby born early. Data on stillbirths in these countries are rarely collected systematically. 6. She denies having any labor contractions. However, most cases of intraamniotic infection detected and managed by obstetrician-gynecologists or other . PPROM raises the risk for infection. When ultrasonography is inconclusive or the clinical situation depends on a precise diagnosis (e.g., when contemplating transport to a tertiary care facility), amniocentesis may help determine whether the membranes are ruptured. Portal of entry into a host. If the infection cannot be prevented, the goal is to prevent the spread of infection between individuals and treat the underlying infection. The most widely used and recommended regimens include intramuscular betamethasone (Celestone) 12 mg every 24 hours for two days, or intramuscular dexamethasone (Decadron) 6 mg every 12 hours for two days.22 The National Institutes of Health recommends administration of corticosteroids before 30 to 32 weeks gestation, assuming fetal viability and no evidence of intra-amniotic infection. It happens more often when the amniotic sac is broken for a long time before birth. Your provider will carefully weigh these risks before making a decision. Antibiotics should be administered to patients with preterm PROM because they prolong the latent period and improve outcomes. Encourage the patient to effectively cough out mucus. Its normal for the membranes to break by themselves, but this usually happens after labor starts. Alleviate or reduce the problems related with the infection. If it happens earlier, your provider weighs the risk of premature birth against the risks of complications such as infection. Who is at risk for umbilical cord prolapse? Copyright 2023 American Academy of Family Physicians. Other recommended site resources for this nursing care plan: Recommended resources and reading materials for risk for infection nursing diagnosis and care plan: Thank you very much for this page. Compromised circulation (e.g., obesity, lymphedema, peripheral vascular disease). How do you develop a nursing care plan? Limit visitors.Restricting visitation reduces the transmission of pathogens. The diagnosis of PROM requires a thorough history, physical examination, and selected laboratory studies. Wash hands with antiseptic soap and water for at least 15 seconds, followed by an alcohol-based hand rub. It depends on factors like the age of the pregnancy and how much amniotic fluid is left. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Corticosteroids decrease perinatal morbidity and mortality after preterm PROM.21 A recent meta-analysis21 found that corticosteroid administration after preterm PROM, versus no administration, reduced the risk of respiratory distress syndrome (20 versus 35.4 percent), intraventricular hemorrhage (7.5 versus 15.9 percent), and necrotizing enterocolitis (0.8 versus 4.6 percent) without an increase in the risk of maternal or neonatal infection. There appears to be no single etiology of preterm PROM. If hands were not in contact with anyone or anything in the room, use an alcohol-based hand rub and rub until dry. endobj Your provider will monitor you closely for signs of infection. These data were collected via a 14 county, 23 hospital population based Perinatal Data System. Limited data are available to help determine whether tocolytic therapy is indicated after preterm PROM. A number of antibiotic regimens are advocated for use after preterm PROM. Ackley and Ladwigs Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning CareWe love this book because of its evidence-based approach to nursing interventions. People have dedicated cells or tissues that deal with the threat of infection. This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions. A more recent article on preterm labor is available. 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. 2. 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). PATIENT EDUCATION 1. She states the she is 37 weeks along and is nervous about the gush of water she experienced so she decided to come to the L&D triage area. Pt denies any uterus tenderness. Immunosuppression such as in people with cancer, recent organ donation and transplantation. Vaginal fluid has a lower pH than amniotic fluid.
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