risk for infection related to rupture of membranes care plan

The patient is to be kept overnight for monitoring and complete bed rest. Zimmerman, S., GruberBaldini, A. L., Hebel, J. R., Sloane, P. D., & Magaziner, J. Gel or wash hands after coughing or expectorating. Interprofessional patient problems focus familiarizes you with how to speak to patients. Studies show PPROM is more likely to affect twin pregnancies. Encourage coughing and deep breathing exercises; frequent position changes.Helps reduce the stasis of secretions in the lungs and bronchial tree. Teach the importance of physical distancing. 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. (2014). Perform measures to break the chain of infection and prevent infection. All reflexes are checked and are intact. Insufficient knowledge to avoid exposure to pathogens. 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. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively sample clinical applications, prioritized action/interventions with rationales a documentation section, and much more! Preterm PROM typically occurs due to a medical condition or pregnancy complication, but it can result from unknown causes. Nursing Diagnosis: Risk for Infection related to contagious skin infection. Other symptoms include a fast heart rate, sore or painful uterus, and amniotic fluid that smells bad. She found a passion in the ER and has stayed in this department for 30 years. 16. A speculum allows your provider to separate your vaginal wall and see your cervix. A more recent article on preterm labor is available. Premature rupture of membranes (water breaking) before you reach full term. Anna Curran. Such patients, if they are stable, may benefit from transport to a tertiary facility. | New Nurse STORYTIME & Tips, NCLEX NGN Study Plan Strategy for Case Studies | Next Generation NCLEX, Left-Sided Heart Failure vs Right-Sided Heart Failure Pathophysiology Nursing NCLEX Review, Left-Sided vs. Right-Sided Heart Failure Nursing Review, Next Generation NCLEX Case Study Sample Questions, Wheezes (High-Pitched) Lung Sound Nursing Review. She denies having any labor contractions. Excessive stress predisposes clients to infection. Diagnostic methods using nitrazine paper and determination of ferning have sensitivities approaching 90 percent.18 The normal vaginal pH is between 4.5 and 6.0, whereas amniotic fluid is more alkaline, with a pH of 7.1 to 7.3. The precise cause and specific predisposing factors are unknown. 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. 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. 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. Please visit using a browser with javascript enabled. Fluids help promote diluted urine, frequent emptying of the bladder, and reducing the stasis of urine. Giving antibiotics to patients with preterm PROM can reduce neonatal infections and prolong the latent period. If it happens earlier, your provider weighs the risk of premature birth against the risks of complications such as infection. View full document. Figure 1 is an algorithm for management of preterm PROM. %xjQ#>q- V]D{2dZ0Z7 m D$=ZKTu)kaOtd5z9 4E~]XB . Some premature infants also have developmental delays later in life. Intraamniotic infection is a common condition noted among preterm and term parturients. People with tuberculosis have reduced immune system response. If your water breaks before 37 weeks, your provider will help you make the safest choice. 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. Educate the patient on what is currently known about the disease: its transmission, complications, and available help. Educate clients and SO (significant other) about appropriate cleaning, disinfecting, and sterilizing items. lovely update, I like the write up,it has really helped me in my project writing. Other people can spread infections or colds to a susceptible patient (e.g., immunocompromised) through direct contact, contaminated objects, or air currents. Demonstrate and allow return demonstration of all high-risk procedures that the patient and/or SO will do after discharge, such as dressing changes, peripheral or central IV site care, and so on.Patient and SO need opportunities to master new skills to reduce susceptibility to infection. (2020). The complications from prematurity are high when the fetus is fewer than 34 weeks gestation. The leading cause of death associated with PROM is infection. Investigate the use of medications or treatment modalities that may cause immunosuppression.Antineoplastic agents, corticosteroids, and so on can suppress immune function. -Pt will be free from any signs and symptoms of infection such as foul smelling/lookingvaginal drainage, elevated temperature, uterus tenderness or rigidness, diminished fetal movement, tachycardia, and hypo-tension throughout rest of pregnancy.-The patient will verbalized 6 signs and symptoms of infection to the nurse. Alleviate or reduce the problems related with the infection. If youre at all unsure whats coming out of your vagina, contact your pregnancy care provider. She received her RN license in 1997. People have dedicated cells or tissues that deal with the threat of infection. To assess for the evidence of ongoing infection. 4 0 obj Use the nursing assessment guidelines below to identify your subjective data and objective data for your risk for infection care plan: 1. These are known as the immune system. Preventing infection is a vital role of all healthcare professionals. Which of the following increases the risk of placental abruption? In the absence of intra-amniotic infection, the physician should attempt to prolong the pregnancy until 34 weeks gestation. Policy. 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 Proper nutrition and a balanced diet support the immune systems responsiveness and enhance the health of all the bodys tissues. One study28 showed that conservative management between 34 and 36 weeks gestational age resulted in an increased risk of chorioamnionitis and a lower average umbilical cord pH. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance. Manage Settings 9. Mode of transmission. After body fluid exposure risk4. Which assessment data indicates a potential infection? 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. When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the risk of infection is low. Using tobacco is a risk factor for developing PROM (as well as other pregnancy complications). Ensure that any articles used are properly disinfected or sterilized before use. Once the sac breaks, you have an increased risk for infection. A sudden gush of clear watery fluid from the vagina is always seen in cases of PROM. Tips to help you get the most from a visit to your healthcare provider: PROM is rupture of the chorion and amnion 1 hour or more before the onset of labor. Fetal Heart Rate is present with a rate 130 bpm. -The nurse will educate the patient on 6 signs and symptoms of infection the patient should watch out for. These factors represent a break in the bodys normal first line of defense and may indicate an infection. According to the patients last menstrual period she is indeed 37 weeks along. 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 . Preterm premature rupture of membranes is the rupture of membranes during pregnancy before 37 weeks gestation. Rough edges or hangnails can harbor microorganisms. Umbilical cord prolapse can occur without any risk factors. <> Buy on Amazon, Silvestri, L. A. Increased fluid intake also helps replace fluid lost during fever and helps thin secretions. In addition, the physician should observe closely for fetal or maternal tachycardia, oral temperature exceeding 100.4F (38C), regular contractions, uterine tenderness, or leukocytosis, which are possible indicators of amnionitis. Contact your pregnancy care provider right away if you believe your membranes have ruptured. It is important to verify the patients estimated due date because this information will direct subsequent treatment. To determine the severity of varicella infection and any affected areas that require special attention or skin care. Previable rupture of membranes also can lead to Potters syndrome, which results in pressure deformities of the limbs and face and pulmonary hypoplasia. Wear gloves when handling patient secretions. Advise all patients with rupture of membranes that they are at increased risk of infection and need hospital care promptly. You have not finished your quiz. Its important to note that if you already have an infection at the time of rupture or develop one afterward, delivery is necessary. Avoid talking, coughing, or sneezing over open wounds or sterile fields. See permissionsforcopyrightquestions and/or permission requests. -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. Prolonged rupture of amniotic membranes before delivery puts the mother and neonate at increased risk for infection. Cloudy amniotic fluid, with strong odor A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP) suite. The risk of placental abruption is increased 15- to 20-fold if an earlier pregnancy had been complicated by placental abruption.6 Other risk factors include chronic hypertension, cocaine use, preeclampsia, age over 35 years, trauma, thrombophilia, cigarette smoking, preterm premature rupture of membranes, chorioamnionitis, and multiparity. Berman, A., Snyder, S. J., Kozier, B., Erb, G. L., Levett-Jones, T., Dwyer, T., & Parker, B. Copyright 2023 RegisteredNurseRN.com. The newborn's immune system is immature and can not yet protect against pathogens - at least for the first few months. PROM occurs in approximately 10% of pregnancies. The human immune system is crucial for survival in a world full of potentially deadly and harmful microbes. (2008). . Monitor white blood cell (WBC) count. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but they are not having contractions. Price, V. A., Smith, R. A., Douthwaite, S., Thomas, S., Almond, D. S., Miller, A. R., & Beadsworth, M. B. Cleveland Clinics Ob/Gyn & Womens Health Institute is committed to providing world-class care for women of all ages. Nursing Dx: Risk for infection related to prolonged rupture of membranes. When the patient touches other people or objects with infected hands, the infection will likely spread. This refers to how the pathogen leaves the reservoir. Vital signs are important markers of infection. The leading cause of death associated with PROM is infection. <> LeMoine F, Moore RC, Chapple A, Moore FA, Sutton E. 3.4. What causes PPROM? A 24 year old pregnant female presents to the L&D triage area complaining of gush of water and constantly feeling wet. Another method providers may use is a fern test or ferning. Advertising on our site helps support our mission. 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. Reservoir. The physician should instill 1 mL of indigo carmine dye mixed in 9 mL of sterile saline. Once the fetal head is engaged, ambulation can be encouraged. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Appropriate evaluation and management are important for improving neonatal outcomes. Portal of entry into a host. We do not endorse non-Cleveland Clinic products or services. Medical-surgical nursing: Concepts for interprofessional collaborative care. Ivanov, A. V., Bartosch, B., & Isaguliants, M. G. (2017). Preterm premature rupture of the membranes (PPROM) is diagnosed when rupture of the amniotic membranes occurs prior to the completion of the 36th week of gestation. Recommended nursing diagnosis and nursing care plan books and resources. If loading fails, click here to try again. Methods A prospective cohort study was completed . 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). This was so helpful thanks for sharing i have understood the interventions well. Pooling of amniotic fluid in the vagina will be visualized during a speculum examination. An example of data being processed may be a unique identifier stored in a cookie. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another. 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. 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. Bacterial vaginosis can produce a similar result. 4. This postpartum . Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified. Additionally, WBC differential may show an increase and decrease in certain infections. Some hospitals may have the information displayed in digital format, or use pre-made templates. In mothers diagnosed with PPROM without evidence . Scratching the infected skin areas will allow the bacteria to transfer into the fingernails and onto the fingerpads. Use of corticosteroids between 32 and 34 weeks is controversial. VS HR 85, BP 130/82, Temp. 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. 10. Using separate eating utensils from the rest of the household will prevent cross-contamination. (2015). 22. However, infection can also be an etiologic factor that causes prelabor rupture of. Nursing Care Plan Name of the Patient: Mrs. FlorenceMedical Diagnosis: Post CSNursing Diagnosis: Risk for infection related to premature rupture of membranesShort-Term Goal: Within the shift, patient will be able to identify ways to reduce risk for infection. The patient can make an informed choice about getting vaccinated when information is available. Yes, the fetus can survive if your water breaks too soon. Assess the patients skin on his/her whole body. We strive for 100% accuracy, but nursing procedures and state laws are constantly changing. xZ[o~7/po$788i.46xCRq,IHM@S;[fw"LG%Br{//X ,n(" Also, impart these duties to the patient and their significant others and know the instances when to perform hand hygiene or 5 moments for hand hygiene:1. Theyll also monitor the fetuss heart rate and movement to make sure it isnt in distress. Portal of exit from the reservoir. Compromised host defenses (e.g., cancer, immunosuppression, AIDS, diabetes mellitus ). After transport to a facility able to care for patients with preterm PROM before 32 weeks gestation, patients should receive daily (or continuous, if indicated) fetal monitoring for contractions and fetal well-being. Administration of corticosteroids after 34 weeks gestation is not recommended unless there is evidence of fetal lung immaturity by amniocentesis. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client CareIdentify interventions to plan, individualize, and document care for more than 800 diseases and disorders. However, its not always a gush. Monitor the patients vital signs and signs of infection. Maintain the client on bed rest if the fetal head is not engaged. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Cervical incompetence in combination with PROM can be a cause of umbilical cord prolapse. Adequate sleep is an essential modulator of immune responses. In older patients, the infection may be present without an increased WBC count. This can cause the amniotic sac to weaken and eventually rupture. Educate the patient and carer about proper wound hygiene through washing the rash with soap and water. Low-grade temperature elevation that appears in older clients must be reported as it could potentially be an infection. Also, having inadequate resources, lack of knowledge, and being malnourished place an individual at high risk of developing an infection. Wound healing alterations caused by infection. In most cases, this occurs near term, but when membrane rupture occurs before 37 weeks gestation, it is known as preterm PROM. Handwashing is the best way to break the chain of infection. Antibiotic may protect against the development of chorioamnionitis in women at risk. 3. Reime, M. H., Harris, A., Aksnes, J., & Mikkelsen, J. Encourage the use of separate utensils for eating. Rupture of membranes is confirmed by the following. Complications from premature birth include breathing difficulties, low body temperature and poor growth. Assess immunization status and history. Numerous risk factors are associated with preterm PROM. Your membranes are sometimes called bag of waters, which is where the term water breaking comes from. Registered Nurse, Free Care Plans, Free NCLEX Review, Nurse Salary, and much more. This ultimately reduces the risk of bladder infection or urinary tract infection. When there is PROM the risk of serious infection is increased (1% versus 0.5% for women with intact membranes). The following methods help break the chain of infection and prevent conditions that may be suitable for microbial growth: 7. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. Interrupting the chain of infection (see image above) is an effective way to prevent the spread of infection. 18. Teach the patient/ carer the proper application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection. Once you are finished, click the button below. 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. The infectious agent in tuberculosis is airborne. 5. Management: Regularly assess the patients stoma and surrounding skin for color, exudates, erythema, and crusting lesions. Place the patient in protective isolation if the patient is at high risk of infection.Protective isolation is set when the WBC indicates neutropenia. 3.2. General physicians do not take adequate travel histories. 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). PROM may occur if the uterus is over-stretched by malpresentation of the fetus, multiple pregnancy or excess amniotic fluid. It also increases your chance of having your baby too early. Assess, monitor, and record the patients vital signs. Delivery before 32 weeks gestation may lead to severe neonatal morbidity and mortality. Infections occur when the natural defense mechanisms of an individual are inadequate to protect them. Client will be free of infection as evidenced by: Maternal temperature remains WNL during labor and fetal heart rate remains between 120 and 160. When the pathogen reaches the host, the body fights off the microorganism. Encourage hand hygiene and explain the importance of proper handwashing. Color of respiratory secretions.Yellow or yellow-green sputum is indicative of respiratory infection. We may earn a small commission from your purchase. Educating the patient about the disease can raise confidence and understanding of the importance of sticking to the guidelines. <> St. Louis, MO: Elsevier. Appearance of urine.Cloudy, turbid, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection. Educate the patient with easy-to-understand words on the pathology of tuberculosis. Here are the common causes of infection and factors that place a patient at risk for infection: Here are some sample patient goals and expected outcomes for patients at risk for infection. These are the classic signs of infection. Antibiotics to prevent infection and prolong the pregnancy. She denies having any labor contractions. Client will maintain or restore defenses. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. Vital signs monitoring including the patients temperature help in the monitoring of possible infections. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Fetal Heart Rate is present with a rate 130 bpm and the patient states she felt the babys last movement about an hour ago. 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. Physicians caring for patients with preterm PROM before viability may wish to obtain consultation with a perinatologist or neonatologist. Your membranes are a fluid-filled sac (also called the amniotic sac) containing amniotic fluid. 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). Diseases, medical conditions, and related nursing care plans for Risk for Infection nursing diagnosis: Assessment is paramount in identifying factors that may precipitate infection. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Coughing is an effective method to expectorate mucus build up to prevent infection. Another common medical intervention is called immunization. Teach the importance of avoiding contact with individuals who have infections or colds. Limit visitors.Restricting visitation reduces the transmission of pathogens. When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the risk of infection is low. It is a common problem in people with low immune system. Evidence suggests that prolonged latency may increase the risk of intra-amniotic infection. The, Sax, H., Allegranzi, B., Uckay, I., Larson, E., Boyce, J., & Pittet, D. (2007). The serious impairment of this system can predispose to severe, even life-threatening, infections. Methylin blue dye should not be used because it has been associated with hyperbilirubinemia and hemolytic anemia in infants.20 Even when ultrasonography is not necessary to confirm PROM, it may help determine the position of the fetus, placental location, estimated fetal weight, and presence of any anomalies. 3 0 obj Do not treat a patient based on this care plan. 1 0 obj ACOG practice bulletin no. No edema is present and UA comes back as negative. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common. Keep a suction machine by the patients bedside. A fern test is ordered and comes back as positive. 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). Trim the patients fingernails and ensure frequent hand hygiene. Determine maternal and fetal status, including estimated gestational age. Handwashing is the single best way to prevent infection. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714616/), (https://www.merckmanuals.com/home/women-s-health-issues/complications-of-labor-and-delivery/prelabor-rupture-of-the-membranes-prom). Patient will demonstrate a meticulous hand washing technique. She has worked in Medical-Surgical, Telemetry, ICU and the ER. -The nurse will verbalize and demonstrate proper hand hygiene techniques to the patient. Assess vital signs and observe for any signs of infection as well as for any signs of respiratory distress. A blue result means the fluid on the paper has a pH of greater than 6.0 and is likely amniotic fluid. Desired Outcome: The patient will remain free from infection as evidenced by the absence of fever and clear stoma. Educate patient on the signs of infection such as the following: Changes in cough or having a new cough. A., & Taylor, R. (2001). Continuously monitor maternal and fetal vitals. GBS infection in a previous baby. endobj Use the nursing interventions below to help you create your nursing care plan for risk for infection: 1. 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. PROM occurs in up to 10% of all pregnancies. Please follow your facilities guidelines and policies and procedures. However, certain conditions or factors may increase the chances of a prolapse occurring. Assist client to learn stress-reducing techniques. Unlike when you pee, you wont be able to hold it in. Congenital disorders that affect your uterus (like. 14. Get useful, helpful and relevant health + wellness information. It happens more often when the amniotic sac is broken for a long time before birth. Data on stillbirths in these countries are rarely collected systematically. 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. 1 It increases the risk of prematurity and leads to a number of other perinatal and. Consider readmission to the hospital for these patients after 24 weeks gestation to allow for close fetal and maternal monitoring. 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. Intervention #1. PATIENT EDUCATION 1. Monitor fetal heart rate continuously. Laboratory and diagnostic study findings. It involves collecting a fluid sample and looking at it under a microscope. PPROM accounts for 25% of all cases of premature rupture of the membranes and is responsible for 30%-40% of all preterm deliveries. If your provider wants to deliver your baby, they may arrange for specialized care (like care from a NICU) to treat your baby when theyre born. Tonsillitis can lead to peritonsillar abscess. Ruptured membranes are known to be a risk factor for subsequent maternal and neonatal infection. However, sometimes it breaks before labor begins or several weeks before labor begins. Learn how your comment data is processed. Proper application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection. This is the final step in the chain of infection. Assess for the following signs and symptoms: 3.1. Choose the letter of the correct answer. This involves your provider inserting a speculum into your vagina.

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