NURSING CARE PLAN - Nursing Crib

<strong>NURSING</strong> <strong>CARE</strong> <strong>PLAN</strong><br />

ASSESSMENT DIAGNOSIS INFERENCE <strong>PLAN</strong>NING INTERVENTION RATIONALE EVALUATION<br />

Subjective:<br />

“Bigla na lang<br />

humilab ang tiyan<br />

ko, parang<br />

manganganak na<br />

ko” (I feel a sudden<br />

contraction, I thought<br />

I am in labor) as<br />

verbalized by<br />

patient.<br />

Objective:<br />

<br />

<br />

<br />

<br />

Continued<br />

uterine<br />

contraction.<br />

Facial mask<br />

of pain.<br />

Irritability.<br />

V/S taken as<br />

follows:<br />

T: 37.3<br />

P: 84<br />

R: 19<br />

Bp: 100/80<br />

<br />

Activity<br />

intolerance<br />

related to<br />

muscle or<br />

cellular<br />

hypersensitivity<br />

.<br />

<br />

Preterm<br />

labor is<br />

defined as<br />

uterine<br />

contractio<br />

ns<br />

occurring<br />

after 20<br />

weeks of<br />

gestation<br />

and before<br />

37<br />

completed<br />

weeks of<br />

gestation.<br />

Risk<br />

factors<br />

include<br />

multiple<br />

geatation,<br />

history of<br />

previous<br />

preterm<br />

labor of<br />

delivery,<br />

abdominal<br />

surgery<br />

during<br />

current<br />

pregnancy<br />

, uterine<br />

anomaly,<br />

<br />

After 8 hours<br />

of nursing<br />

interventions<br />

, the patient<br />

will use<br />

identified<br />

techniques<br />

to enhance<br />

activity<br />

intolerance.<br />

Independent:<br />

Assess status of<br />

the client and<br />

fetus.<br />

<br />

<br />

<br />

<br />

Encourage bed<br />

rest with patient<br />

in side lying<br />

position.<br />

Apply external<br />

uterine and fetal<br />

monitoring.<br />

Monitor patient’s<br />

vital signs<br />

closely, every 15<br />

minutes.<br />

Instruct patient to<br />

report any<br />

feelings of<br />

difficulty of<br />

breathing or<br />

chest pain,<br />

dizziness,<br />

<br />

<br />

<br />

<br />

<br />

Assessment<br />

provides a<br />

baseline date<br />

for future<br />

comparisons.<br />

Bed rest<br />

relieves<br />

pressure of the<br />

fetus on the<br />

cervix.<br />

Uterine and<br />

fetal monitoring<br />

provides<br />

evidence of<br />

maternal and<br />

fetal well being.<br />

Maternal pulse<br />

over 120 beats<br />

per minute or<br />

persistent<br />

tachycardia or<br />

tachypnea,<br />

chest pain,<br />

dyspnea and<br />

adventitious<br />

breath sounds<br />

may indicate<br />

impending<br />

pulmonary<br />

edema.<br />

Early<br />

recognition of<br />

possible<br />

adverse effects<br />

allows for<br />

prompt<br />

intervention.<br />

After 8<br />

hours of<br />

nursing<br />

intervention<br />

s, the<br />

patient was<br />

able to use<br />

identified<br />

techniques<br />

to enhance<br />

activity<br />

intolerance.

---

history of<br />

cone<br />

biopsy,<br />

maternal<br />

age<br />

younger<br />

than 20 or<br />

older than<br />

age 35.<br />

<br />

nervousness and<br />

irregular heart<br />

beats.<br />

Monitor uterine<br />

contractions,<br />

including<br />

frequency and<br />

domain.<br />

<br />

Monitor of<br />

uterine<br />

contractions<br />

provides<br />

evidence of<br />

effective<br />

therapy.<br />

Collaborative:<br />

Obtain diagnostic<br />

studies including<br />

complete blood<br />

count,<br />

hemoglobin and<br />

hematocrit, urine,<br />

vaginal ang<br />

cervical cultures<br />

as ordered.<br />

<br />

Urine, vaginal,<br />

and cervical<br />

cultures help to<br />

rule out<br />

infection as a<br />

causative factor<br />

for preterm<br />

labor.