Submitted By: Domingo, Danna Marie V.

BSN ² 2A

July 14, 2011

Nursing Care Plan
ASSESSMENT Subjective: Bigla na lang humilab ang tiyan ko, parang manganganak na ko (I feel a sudden contraction, I thought I am in labor) as 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 DIAGNOSIS Activity intolerance related to muscle or cellular hypersensitivity PLANNING After 8 hours of nursing interventions, the patient will use identified techniques to enhance activity intolerance. INTERVENTION Independent: y Assess status of the client and fetus. RATIONALE EVALUATION After 8 hours of nursing interventions, the patient was able to use identified techniques to enhance activity intolerance.

y

Assessment provides a baseline data for future comparisons. Bed rest relieves pressure of the fetus on the cervix. Fetal monitoring provides evidence of maternal and fetal well being.

y

Encourage bed rest with patient in side lying positon. Apply external uterine and fetal monitoring

y

y

y

y

Monitor patient s vital signs closely, every 15 minutes.

y

Maternal pulse over 120 beats per minute or persistent tachycardia or tachypnea, chest pain, dyspnea and adventitious breath sounds may indicate impending pulmonary edema.

vaginal. dizziness. urine.y Instruct patient to report any feelings of difficulty of breathing or chest pain. Collaborative: y Obtain diagnostic studies including complete blood count. including frequency and domain. Monitor uterine contractions. y y Monitor of uterine contractions provides evidence of effective therapy. hemoglobin and hematocrit. y Early recognition of possible adverse effects allows for prompt intervention. y Urine. . vaginal and cervical cultures as ordered. and cervical cultures help to rule out infection as a causative factor for preterm labor. nervousness and irregular heart beats.

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