Carla Hernandez - Umbilical Cord Prolapse,WELL EXPLAINED 100% correct.

CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) “A prolapsed umbilical cord occurs when the umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix. This results in cord compression and compromised fetal circulation.” (Holman et al., 2019) “Prolapse of the umbilical cord (displacement of the umbilical cord in front of or beside the fetus) is more likely when the fit is poor between the fetal presenting part and the maternal pelvis when membranes rupture. When the fit is good, the presenting part fills the pelvic opening, leaving little room for the cord to slip down. Cord prolapse is more likely if any of the following conditions are present: • A fetus that remains at high station. • A very small fetus. • Breech presentation (the footling breech is more likely to be complicated by a prolapse cord because the feet and legs are small and do not fill the pelvis well. • Transverse lie • Hydramnios (often associated with abnormal presentations; also, the unusually large amount of fluid exerts more pressure to push the cord out).” (McKinney, James, Murray, Nelson, & Ashwill, 2018) DIAGNOSTIC TESTS (REASON & RESULTS) PATIENT INFORMATION EXPECTED PHYSICAL FINDINGS • Ultrasound- confirms presence of FHR activity. • External Fetal monitoring - confirm prolonged deceleration Carla Hernandez, Female Adm DX: Umbilical Cord Prolapse DOB: 10/1/1987 (32y) Height: 165 cm Weight: 81 kg Allergies: No Known Adm on: 8/15/2020 • “Client reports that they feel something coming through the vagina.” • “Visualization or palpation of the umbilical cord protruding from the introitus.” • “FHR monitoring shows variable or prolonged deceleration.” • “Excessive fetal activity followed by cessation of movement; suggestive of severe fetal hypoxia.” (Holman et al., 2019 ANTICIPATED NURSING INTERVENTIONS • Call for assistance as needed • Do not leave the client alone • “Using a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. Stay in this position until the delivery on the baby.” • “Reposition the client in a knee-chest, Trendelenburg, or a side-lying position with a rolled towel under the clients right or left hip to relieve pressure on the cord.” • “Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow.” • Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and