Problem Scientific Basis Goals/ Objectives Intervention Rationale Evaluation

S>”Gikapoy nako sige og Preterm labor is labor that At the end of my 8-hour span a. Monitor maternal vital Serves as a baseline data. Any Goal met as evidenced by:
higda. Usahay nagalingkod- occurs before the end of of care, patient will be able signs, and continuous deviation from the normal
lingkod pud ko pero diri lang week 37 of gestation. to: monitoring of fetal heart may indicate infection, pain a. Patient verbalized
pud kutob... di ko katindog og A woman who is in preterm tone and uterine and/ or complications. understanding of
lakaw-lakaw”, as verbalized labor is usually first admitted a. Verbalize understanding contractions q15 mins. situation/ risk factors and
by the patient to the hospital and placed on of situation/ risk factors b. Assist client in ADLs and Assisting the client in of individual treatment
bed rest to relieve the and of individual in repositioning on a repositioning on a regular regimen
O>Age: 35 yrs. old pressure of the fetus on the treatment regimen regular schedule schedule aids in conservation b. Maintained skin integrity
>33 2/7 weeks AOG cervix. Following initial b. Maintain skin integrity of energy and prevents as evidenced by absence
>Fundic ht.: 29 cm therapy, women in preterm c. Perform ADLs and change development of pressure of pressure sores
>(+) irregular contractions labor can be safely cared for of position without sores. c. Performed ADLs and
with 10-12 mins duration at home as long as they can exerting much effort c. Encourage increase oral To increase hydration. This repositioning without
>G1P0 dependably remain on almost d. Demonstrate techniques fluid intake aids to stop contractions. exerting much effort.
>LMP: December 15, 2009 complete bed rest, drink to wile away the d. Provide safety for the Safety measure should be Patient asked assistance
EDC: September 22, 2010 enough fluid to remain well boredom client observed to prevent on transportation during
>Side drip of Isoxsuprine drip: hydrated and take an oral accidents/ injuries that may urination and BM.
D5W 500 cc + 5 amp; tocolytic agent. aggravate patient’s condition. d. Demonstrated techniques
Isoxsuprine @ 40 gtts/ min, e. Place patient on a Semi-fowlers position to wile away boredom
titrate @ 30 mins. Noted Source: Pillitteri, Adele. comfortable position promotes lung expansion; left such as watching TV and
>Isoxsuprine 10 mg 1 tab PO Maternal and Child Health (semi-fowlers position or side-lying position prevent engaging in socialization
q6 hours ordered be given Nursing: Care of the on left side-lying position) hypotension to medical staffs and
when Isoxsuorine side drip is Childbearing and Childbearing f. Provide a calm A calm environment is a student nurses
@ the level of 100 cc Family. 5th Ed. pp. 417-419 environment; adequate conducive milieu for patient
>CBR s BRP rest and sleep to have adequate rest and
sleep, thus prevent fatigue.
A>Impaired physical mobility
r/t prescribed movement g. Educate client about the Through education, client will
restrictions 2° preterm labor situation and of the be able to gain knowledge on
treatment regimen the situation and understand
the importance of treatment
prescribed. Client
participation can also be
acquired.
h. Assist in range of motion Promote adequate circulation
exercise/ movement but of blood and O₂ into the
not enough to increase O₂ system.
demand/ compensation
i. Instruct patient on Such activities diverts
diversional activities such patients attention, thus
as watching TV, reading would wile away or prevent
books, working on a boredom
project and socialization
j. Maintain CBR s BRP as Increased movement
ordered increases the need for O₂
k. Administer prescribed Such medication prevents
medications such as preterm labor and stop
Isoxsuprine and contractions.
regulation of prescribed
IVF flow rate