NURSING CARE PLAN
Subjective: “Bigla na lang humilab ang tiyan ko, parang manganganak na ko” (I feel a sudden
contraction, I thought I am in labor) as
Activity intolerance related to muscle or cellular hypersensitivity .
INFERENCE Preterm labor is defined as uterine contractio ns occurring after 20 weeks of gestation and before 37 completed weeks of gestation. Risk factors include multiple geatation, history of previous preterm labor of delivery, abdominal surgery during current pregnancy , uterine anomaly,
After 8 hours of nursing interventions , the patient will use identified techniques to enhance activity intolerance.
Independent: Assess status of the client and fetus.
Assessment provides a baseline date for future comparisons. Bed rest relieves pressure of the fetus on the cervix. Uterine and fetal monitoring provides evidence of maternal and fetal well being. Maternal pulse over 120 beats per minute or persistent tachycardia or tachypnea, chest pain, dyspnea and adventitious breath sounds may indicate impending pulmonary edema. Early recognition of possible adverse effects allows for prompt intervention.
After 8 hours of nursing intervention s, the patient was able to use identified techniques to enhance activity intolerance.
verbalized by patient. Objective: Continued uterine contraction. Facial mask of pain. Irritability. V/S taken as follows: T: 37.3 P: 84 R: 19 Bp: 100/80
Encourage bed rest with patient in side lying position. Apply external uterine and fetal monitoring.
Monitor patient’s vital signs closely, every 15 minutes.
Instruct patient to report any feelings of difficulty of breathing or chest pain, dizziness,
history of cone biopsy, maternal age younger than 20 or older than age 35.
nervousness and irregular heart beats. Monitor uterine contractions, including frequency and domain.
Monitor of uterine contractions provides evidence of effective therapy.
Collaborative: Obtain diagnostic studies including complete blood count, hemoglobin and hematocrit, urine, vaginal ang cervical cultures as ordered.
Urine, vaginal, and cervical cultures help to rule out infection as a causative factor for preterm labor.