CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) “Rupture of the amniotic sac before the
... [Show More] onset of true labor, regardless of length of g estation, is called premature rupture of the membranes (PROM). A related term, preterm premature rupture of the membranes, describes membranes rupture earlier than the end of the 27th week of gestation, with or without contractions. PROM may be a normal occurrence that precedes term birth at 38 weeks or later, even if labor induction is needed to initiate labor. However, PROM is often associated with preterm labor (PTL), with the greatest risk of preterm birth occurring before completing 34 weeks of gestation. However, brief delays of an inevitable preterm birth from PPROM can be enable interventions to reduce these risks.” (McKinney, James, Murray, Nelson, & Ashwill, 2018) DIAGNOSTIC TESTS (REASON & RESULTS) PATIENT INFORMATION EXPECTED PHYSICAL FINDINGS • “A positive nitrazine paper test (blue, pH 6.5 to 7.5)” • “A positive ferning test is conducted on amniotic fluid to verify rupture of membranes.” (Holman et al., 2019) Brenda Patton (F) 1/6/2002 (18y) Height 165 cm Weight 68 kg Adx DX Rupture of membranes Adm on 07/24/2020 Allergies: No known • “Client reports a gush or leakage of clear fluid from vagina.” • “Presence of clear fluids” (Holman et al., 2019) ANTICIPATED NURSING INTERVENTIONS • “Nursing management depends on gestational duration, if there is evidence of infection, or an indication of fetal or maternal compromise.” • “Prepare for birth if indicated.” • “Obtain vaginal/rectal cultures for streptococcus beta-hemolytic.” • “Obtain vaginal cultures for chlamydia and Neisseria gonorrhoeae” • “limit vaginal exams.” • “Provide reassurance to reduce anxiety.” • “Assess vital signs every 2 hrs. Notify the provider of a temperature greater than 38 C (100F)” • “Monitor FHR and uterine contractions.” • “Encourage hydration.” • “Obtain a CBC” • “Anticipate a prescription for 7-day course of broad-spectrum antibiotics.” (Holman et al., 2019) Show Less [Show Less]