ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:“Bigla na langhumilab ang tiyanko, parangmanganganak ako” (I felt a suddencontraction, I thoughtI am in labor) asverbalized bypatient.

Objective:

Continueduterinecontraction.

Facial maskof pain.

Irritability.

Activityintolerancerelated tomuscle orcellularhypersensitivity

Pretermlabor isdefined asuterinecontractionsoccurringafter 20weeks ofgestationand before37completedweeks ofgestation.Riskfactorsincludemultiplegeatation,history ofpreviouspretermlabor ofdelivery,abdominalsurgeryduringcurrentpregnancy

After 8 hoursof nursinginterventions, the patientwill useidentifiedtechniquesto enhanceactivityintolerance

Independent:

Assess status ofthe client andfetus.

Encourage bedrest with patientin side lyingposition.

Apply externaluterine and fetalmonitoring.

Monitor patient’svital signsclosely, every 15minutes.

Assessmentprovides abaseline datefor futurecomparisons.

Bed restrelievespressure of thefetus on thecervix.

Uterine andfetal monitoringprovidesevidence ofmaternal andfetal well being.

Maternal pulseover 120 beatsper minute orpersistenttachycardia ortachypnea,chest pain,dyspnea andadventitiousbreath sounds

After 8hours ofnursinginterventions, thepatient wasable to useidentifiedtechniquesto enhanceactivityintolerance

, uterineanomaly, history ofconebiopsy,maternalageyoungerthan 20 orolder thanage 35.

Instruct patient toreport anyfeelings ofdifficulty ofbreathing orchest pain,dizziness, nervousness andirregular heartbeats.

Monitor uterinecontractions,includingfrequency anddomain.

Collaborative: Obtain diagnosticstudies includingcomplete bloodcount,hemoglobin andhematocrit, urine,vaginal angcervical culturesas ordered.

may indicateimpendingpulmonaryedema.

Earlyrecognition ofpossibleadverse effectsallows forpromptintervention.

Monitor ofuterinecontractionsprovidesevidence ofeffectivetherapy.

Urine, vaginal,and cervicalcultures help torule outinfection as acausative factorfor pretermlabor.