Nursing Care Plan Preterm Labor
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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION Subjective: “Bigla na lang humilab ang tiyan ko, parang manganganak ako” (I felt a sudden contraction, I thought I am in labor) as verbalized by patient. Objective: Continued uterine contraction. Facial mask of pain. Irritability Activity intolerance related to muscle or cellular hypersensiti vity 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, After 8 hours of nursing intervention s , the patient will use identified techniques to enhance activity intolerance Independent: Assess status of the client and fetus. Encourage bed rest with patient in side lying position. Apply external uterine and fetal monitoring. Monitor 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 After 8 hours of nursing intervention s, the patient was able to use identified techniques to enhance activity intolerance
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Transcript of Nursing Care Plan Preterm Labor
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.
