Copyright 2023 American Academy of Family Physicians. 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. Patient information: See related handout on preterm premature rupture of membranes, written by the authors of this article. Risk for Ineffective Thermoregulation Temperature instability is observed with neonatal sepsis and meningitis, either in response to pyrogens secreted by the bacterial organisms or from sympathetic nervous system instability. Nursing care plans: Diagnoses, interventions, & outcomes. Varicella infection is generally treated using antiviral therapy. Ideally, these treatments allow your pregnancy to progress to at least 34 weeks. -The nurse will educate the patient on the importance of refraining from any type of sexual intercourse and tampons usage until after pregnancy. This was so helpful thanks for sharing i have understood the interventions well. Assess, monitor, and record the patients vital signs. 7. Risk for infection related to loss of protective barrier as evidence by positive ferns test. Some premature infants also have developmental delays later in life. Laboratory and diagnostic study findings. This is a rare but serious complication in which the uterus tears along the scar line from a prior C-section or major uterine surgery. Ensure all fluid containers are covered or capped. Join the nursing revolution. All Rights Reserved. endobj The human immune system is crucial for survival in a world full of potentially deadly and harmful microbes. A more recent article on preterm labor is available. Elevated temperature.Fever is often the first sign of an infection. 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. 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. Management of Ruptured Membranes at Term - Medscape Vaginal fluid has a lower pH than amniotic fluid. Some of the most common causes include: The most obvious symptom of your membranes rupturing is feeling a gush of fluid from your vagina. Studies have shown that labor induction clearly is beneficial at or after 34 weeks gestation. Pooling of amniotic fluid in the vagina will be visualized during a speculum examination. 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. If infection occurs, teach the patient to take anti-infectives as prescribed. PROM occurs in up to 10% of all pregnancies. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. General physicians do not take adequate travel histories. Physicians caring for patients with preterm PROM before viability may wish to obtain consultation with a perinatologist or neonatologist. Nursing diagnoses handbook: An evidence-based guide to planning care. most successful method in teaching nursing students infection controlE-learning or lecture? In most cases, this occurs near term, but when membrane rupture occurs before 37 weeks gestation, it is known as preterm PROM. It also increases your chance of having your baby too early. Premature rupture of membranes (water breaking) before you reach full term. This includes precautions like bed rest, medications and frequent monitoring for infection or fetal distress. Portal of entry into a host. 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. Your membranes are sometimes called bag of waters, which is where the term water breaking comes from. In this condition, the sac (amniotic membrane) surrounding your baby breaks (ruptures) before week 37 of pregnancy. 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. Instruct client not to share personal care items (e.g., toothbrush, towels, etc.). 217: Prelabor Rupture of Membranes. 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. The patient is to be kept overnight for monitoring and complete bed rest. During pregnancy, a fluid-filled sac called the amniotic sac surrounds and protects the fetus. If it happens earlier, your provider weighs the risk of premature birth against the risks of complications such as infection. Another common medical intervention is called immunization. Insufficient knowledge to avoid exposure to pathogens. Infections can become quite serious. This is also universally used for those who are at high risk for infection. American College of Obstetricians and Gynecologists. PPEs protect carers and prevent the transfer of infection to other people. Scratching the infected skin areas will allow the bacteria to transfer into the fingernails and onto the fingerpads. Clinical manifestations PROM is marked by amniotic fluid gushing from the vagina. Infections occur when the natural defense mechanisms of an individual are inadequate to protect them. (2015). Encourage increased fluid intake unless contraindicated (e.g., heart failure, kidney failure). Wash hands with antiseptic soap and water for at least 15 seconds, followed by an alcohol-based hand rub. Initiate specific precautions for suspected agents as determined by CDC protocol. Prematurity, congenital defects, and maternal complications such as premature rupture of membranes (PROM) or . Once breakage occurs the baby is not in a sterile membrane anymore and is . These include: The biggest concern with PROM is premature birth. 22. This is the way the pathogen transfers from the reservoir to the host. . 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). 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. Educate patient on the signs of infection such as the following: Changes in cough or having a new cough. Premature Rupture of Membranes: Causes & Treatment - Cleveland Clinic Yes, the fetus can survive if your water breaks too soon. Avoid talking, coughing, or sneezing over open wounds or sterile fields. Typically, your membranes rupture after labor (or contractions) begins. This is the final step in the chain of infection. 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. Treatment can be started as soon as an infection is identified. 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. 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. On the other hand, isolation also protects the patient from possible cross-contamination from carers, family, friends, or healthcare staff. Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified. Patients should be informed and well-educated by nurses on recognizing the signs of infection and how to reduce their risk. Maintain strict asepsis for dressing changes, wound care, intravenous therapy, and catheter handling. Additionally, without the protection of amniotic fluid and the amniotic sac, the fetus and your uterus are at risk for infection. 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". 98.7, O2 Sat 98% on RA, RR 18. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Adequate nutrition enables the body to maintain and rebuild tissues and helps keep the immune system functioning well. A temperature of greater than 37.7 (99.8 F) may indicate infection; a very high temperature accompanied by sweating and chills may indicate septicemia. Preterm PROM (or PPROM) is when the amniotic sac breaks before 37 weeks of pregnancy. Desired Outcome: The patient will remain free from infection as evidenced by the absence of fever and clear stoma. Uterine rupture. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but they are not having contractions. Involving the patient in the early identification of the presence of an infection can improve the success of treatment once started. 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. Sometimes, your provider can visually confirm the rupture of membranes if they see pooling of amniotic fluid at the top of your vagina during this exam. PPROM raises the risk for infection. A sudden gush of clear watery fluid from the vagina is always seen in cases of PROM. Care plan diagnosis: Potential for infection related to rupture of Get useful, helpful and relevant health + wellness information. If the rash leads to other skin breakdown which then gets infected, antibiotics is prescribed. When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the risk of infection is low. The most important part of the care plan is the content, as that is the foundation on which you will base your care. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. Your pregnancy care provider will watch for signs of fetal distress and infection to determine when they should deliver your baby. Risk for Infection Care Plan and Nursing Diagnosis - Nurseslabs If your membranes rupture at term (37 weeks of pregnancy), its usually from your amniotic membranes weakening from the pressure of contractions. Teach the patient how to perform proper hand hygiene. Improving compliance with hand hygiene in hospitals. Nursing Diagnosis: Risk for Infection related to inflammation of the tonsils. Intrapartum Management of Intraamniotic Infection | ACOG The nurse is reviewing orders on a patient admitted for preterm premature rupture of membranes. These are the classic signs of infection. For an infant delivered vaginally to mothers with active recurrent genital herpes, the risk of infection is 5% and emperic treatment is not required. 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. Another study29 of 430 women with preterm PROM revealed that there was no improvement in major or minor neonatal morbidity after 34 weeks gestation. Client will be free of infection as evidenced by: Maternal temperature remains WNL during labor and fetal heart rate remains between 120 and 160. Preterm Premature Rupture of Membrane - NursingAnswers.net 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. Perform a focused assessment on the oropharyngeal region, particularly checking for any collection of abscess. This information will help the patient understand the importance of lifestyle changes to avoid secondary infection and the spread of infection to others. Fifty percent of infants with rupture at 19 weeks gestation or earlier are affected by Potters syndrome, whereas 25 percent born at 22 weeks and 10 percent after 26 weeks gestation are affected.32 Patients should be counseled about the outcomes and benefits and risks of expectant management, which may not continue long enough to deliver a baby that will survive normally. Consultation with a neonatologist and physician experienced in the management of preterm PROM may be beneficial. They can then collect a sample of fluid for testing. Fetal Heart Rate is present with a rate 130 bpm. 3. {`!lC[OW|W9XgVibMaAp\Qx- 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. %xjQ#>q- V]D{2dZ0Z7 m D$=ZKTu)kaOtd5z9 4E~]XB . This can transpire via contact, airborne, sexual contact, or sharing of IV drug paraphernalia. Use the nursing assessment guidelines below to identify your subjective data and objective data for your risk for infection care plan: 1. Berman, A., Snyder, S. J., Kozier, B., Erb, G. L., Levett-Jones, T., Dwyer, T., & Parker, B. 9. Which physician order will the nurse question? A temperature of up to 38 C (100.4 F) 48 hours post-op is usually related to surgical stress after 48 hours. Management: SEE ALSO: Nursing Diagnosis Complete List and Guide . Chest imaging appearance of COVID-19 infection. 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. Compromised host defenses (e.g., radiation therapy, organ transplant, medication therapy). Ferning refers to the fern-like pattern of dry amniotic fluid. A fern test is ordered and comes back as positive. Situation III. 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. It depends on factors like the age of the pregnancy and how much amniotic fluid is left. PROM is rupture of the chorion and amnion 1 hour or more before the onset of labor. Manage Settings 20. Risk for Infection Nursing Diagnosis & Care Plan | NurseTogether 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. There are few data to guide the care of patients without documented pulmonary maturity. Very low WBC count may indicate a severe risk for infection. Monitor white blood cell (WBC) count. Nitrazine test tape turns a blue-green color. 12. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. 4 0 obj Intraamniotic infection is a common condition noted among preterm and term parturients. Mother states / shows are free of any signs of infection. Chorioamnionitis | Cedars-Sinai If your membranes rupture too soon, the fetus is at risk for premature birth or infection. View full document. cancer, ongoing chemotherapy, diabetes, etc.). 2. These complications include respiratory issues and trouble staying warm. History of previous genital herpes with unknown culture result and infant delivered vaginally or by C-section after rupture of membranes. Signs and symptoms include localized swelling, localized redness, pain or tenderness, loss of function in the affected area, palpable heat. 15. Continually assess for signs of infection. Risk factors in premature rupture of membranes - PubMed Do not treat a patient based on this care plan. Observe and report if an older client has a low-grade fever or new onset of confusion. When the pathogen reaches the host, the body fights off the microorganism. Medical-surgical nursing: Concepts for interprofessional collaborative care. Encourage coughing and deep breathing exercises; frequent position changes.Helps reduce the stasis of secretions in the lungs and bronchial tree. Preterm premature rupture of the membranes (PPROM) is a pregnancy complication. Prevent infection and other potential complications. 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. Begin taking temperature every 2 hours after rupture of membranes and more often as indicated. Studies show PPROM is more likely to affect twin pregnancies. Adequate sleep is an essential modulator of immune responses. Delivering within 24 hours is usually the safest option. Background More than 2 million third-trimester stillbirths occur yearly, most of them in low- and middle-income countries. Figure 1 is an algorithm for management of preterm PROM. Alleviate or reduce the problems related with the infection. <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 11 0 R 40 0 R 41 0 R] /MediaBox[ 0 0 595.32 841.92] /Contents 4 0 R/Group<>/Tabs/S>>
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