please help me in my nursing care plan.. my patient was in labor a 30 year-old was rushed to the ER because of labor pains. IE reveals 2cm dilatation,and ROM,station -1. what would be the posible risk or diagnosis of her ?
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What does your OB textbook tell you are the risks of labor? Those will be the same risks this patient is subject to. Those then become possible anticipated problems.
Seems to me that someone who has been rushed to the hospital is at risk for precipitous labor. Wouldn't you be a bit scared? Problems of precipitous delivery are (this should also be in your textbook):
accelerated dilatation and fetal descent
a premature birth
increased vaginal show
However, as with any patient, you would have done an assessment of this patient. Since a care plan is your written documentation of your problem solving process, you need to identify her nursing problems. To do that you need to distinguish what her abnormal assessment data is in order to properly diagnose. Some items you might have noticed were that she was excited or anxious; nauseated; had contractions that were painful and increased in frequency, duration and severity; ruptured membranes; brown mucus drainage; fatigued; urinary problems; statements by the patient indicating she didn't know what to expect with regard to any aspect of the birth process or her care during labor. All of these, if present, are evidence that will support nursing diagnoses.
acute pain ..and her age can be a factor in some complication
A potential complication would require you to use a "Risk for" diagnosis. Age would be a risk factor of what OB complication? What are you thinking of? I'm not following you.
Keep in mind that nursing diagnoses are merely shortened labels that represent a defined nursing problem. I am pretty familiar with most of the nursing diagnoses and the only nursing diagnoses that are specifically for OB patients are Effective, Ineffective and Interrupted Breastfeeding.
I would want more of a history...Gravida, Para? previous c-section? where is the placenta attached? any prenatal care? possible abruption or just moving fast toward delivery. You could go many ways with this.