This nursing care plan diagnosis, and interventions for the following conditions: Premature Rupture of Membranes, PROM, or ROM (Rupture of Membranes)
What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
Nursing Care Plan for: Premature Rupture of Membranes, PROM, or ROM (Rupture of Membranes)
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.
Scenario: |
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A 24 year old pregnant female presents to the L&D triage area complaining of “gush of water” and constantly feeling wet. She denies having any labor contractions. 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. According to the patients last menstrual period she is indeed 37 weeks along. A fern test is ordered and comes back as positive. VS HR 85, BP 130/82, Temp. 98.7, O2 Sat 98% on RA, RR 18. All reflexes are checked and are intact. No edema is present and UA comes back as negative. Pt denies any uterus tenderness. Fetal Heart Rate is present with a rate 130 bpm and the patient states she felt the baby’s last movement about an hour ago. The patient is to be kept overnight for monitoring and complete bed rest.
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Nursing Diagnosis: |
| Risk for infection related to loss of protective barrier as evidence by positive ferns test. |
Subjective Data: |
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A 24 year old pregnant female presents to the L&D triage area complaining of “gush of water” and constantly feeling wet. She denies having any labor contractions. 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. Pt denies any uterus tenderness and the patient states she felt the baby’s last movement about an hour ago.
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Objective Data: |
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According to the patients last menstrual period she is indeed 37 weeks along. A fern test is ordered and comes back as positive. VS HR 85, BP 130/82, Temp. 98.7, O2 Sat 98% on RA, RR 18. All reflexes are checked and are intact. No edema is present and UA comes back as negative. Pt denies any uterus tenderness. Fetal Heart Rate is present with a rate 130 bpm. The patient is to be kept overnight for monitoring and complete bed rest.
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Nursing Outcomes: |
| -Pt will be free from any signs and symptoms of infection such as foul smelling/looking vaginal 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.
-The patient will verbalized the importance of refraining from sexual intercourse of any type or usage of tampons until after pregnancy. |
Nursing Interventions: |
| -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.
-The nurse will educate the patient on 6 signs and symptoms of infection the patient should watch out for. -The nurse will verbalize and demonstrate proper hand hygiene techniques to the patient. -The nurse will educate the patient on the importance of refraining from any type of sexual intercourse and tampons usage until after pregnancy. |