Renetria Drake 09/08/15

Nursing of the Childbearing Family

Nursing Care Plan (ADPIE)
Assessment
Objective Data
FHR variable 60130 during 15min
observations.

Diagnosis
Ineffective fetal
tissue perfusion
related to
impaired gas
exchange during
labor and
delivery.

Planning
Client Goal
Fetus will display
a heart rate
within normal
limits 110160bpm as
evidence by
absence of fetal
heart late
decelerations,
marked variables
or baseline
changes.

Implementatio
Rationale
Evaluation
n
Independent Interventions

1. Monitor fetal
HR q15 min.

2. Reposition
client if nonreassuring
patterns occur.

To obtain
baseline. FHR
baseline WNL is
110-160bpm with
baseline
variability of 610bpm. Nonreassuring
findings required
immediate
intervention
Changing
positions can
relieve pressure
on the umbilical
cord, allowing
more blood to
flow through it
and prevents
supine
hypotension
which decreases
blood flow to

Met. FHR was

observed q15m in
to have late
decels. 130 to 60
bpm

Met. Patient was

repositioned to
alternating sides
however this
resolved FHR
issues only briefly
if at all. FHR
60bpm

http://www.mea.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter_8_Nursing_Care_D
uring_Labor_and_Pain_Management.pdf
Ricci, Susan. Essential of Maternity, Newborn, and Womens Health Nursing 3rd Ed. Lippincott Williams &
Wilkins, 2009, 2013.

Renetria Drake 09/08/15

placenta.
3. Provide oxygen
by mask at 8-10L
if non-reassuring
patterns occur.

4. Stop Pitocin if
non-reassuring
patterns occur.

5. Prepare for
expeditious
surgical birth if
not corrected in
30 minutes.

Subjective Data
Client states she is in
pain and very
fatigued.

Theory
(cite references)
Late
decelerations are
associated with
uteroplacental

Goal Evaluation
Met. Variable FHR
was relieved but
only momentarily
with client

Increase
oxygenation of
mothers blood
increases oxygen
delivery to the
fetus.
Pitocin intensifies
uterine
contractions
which decrease
placental blood
flow.
Non reassuring
FHR patterns
indicate hypoxia;
immediate
delivery often
becomes the only
safe option to
protect the fetus
from harm.

Met. Patient
received oxygen
at 8L.

Met. Pitocin was

discontinued.

Met. Patient had a

Foley placed,
given IV fluids,
surgical site
prepped by
surgical clippers
and taken to OR
for surgery.

Interdependent Interventions
1. Consult
physician of nonreassuring FHR
patterns.

May required
emergency Csection.

Met. Physician
consulted.

http://www.mea.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter_8_Nursing_Care_D
uring_Labor_and_Pain_Management.pdf
Ricci, Susan. Essential of Maternity, Newborn, and Womens Health Nursing 3rd Ed. Lippincott Williams &
Wilkins, 2009, 2013.

Renetria Drake 09/08/15

insufficiency,
which occurs
when blood flow
within the
intervillous space
is decreased to
the extent that
fetal hypoxia or
myocardial
depression exists.
Chronic episodes
are less likely to
be corrected.
Ricci, Susan.
Essential of
Maternity,
Newborn, and
Womens Health
Nursing 3rd Ed.
Lippincott
Williams &
Wilkins, 2009,
2013.

repositioning.
Consulted
physician. Client
underwent
emergency Csection at end of
shift.

2. Consult
anesthesiologist
for epidural.

Pain management
for medical
intervention.

Met.
Anesthesiologist
administered
epidural prior to
c-section.

http://www.mea.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter_8_Nursing_Care_D
uring_Labor_and_Pain_Management.pdf
Ricci, Susan. Essential of Maternity, Newborn, and Womens Health Nursing 3rd Ed. Lippincott Williams &
Wilkins, 2009, 2013.