NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective:  Activity  Preterm  After 8 hours  Assess status of  Assessment  After 8
intolerance of nursing the client and provides a hours of
“Bigla na lang
labor is
related to interventions fetus. baseline date nursing
humilab ang tiyan muscle or defined as , the patient for future intervention
ko, parang cellular uterine will use comparisons. s, the
manganganak na hypersensitivity contractio identified  Encourage bed  Bed rest patient was
ko” (I feel a sudden . ns techniques rest with patient relieves able to use
contraction, I thought to enhance in side lying pressure of the identified
I am in labor) as occurring
activity position. fetus on the techniques
verbalized by after 20 intolerance. cervix. to enhance
patient. weeks of  Apply external  Uterine and activity
gestation uterine and fetal fetal monitoring intolerance.
Objective: and before monitoring. provides
37 evidence of
 Continued maternal and
uterine completed
fetal well being.
contraction. weeks of  Monitor patient’s  Maternal pulse
gestation. vital signs over 120 beats
 Facial mask Risk closely, every 15 per minute or
of pain. factors minutes. persistent
include tachycardia or
 Irritability. tachypnea,
multiple
chest pain,
 V/S taken as geatation, dyspnea and
follows: history of adventitious
previous breath sounds
T: 37.3 preterm may indicate
P: 84 impending
R: 19 labor of
pulmonary
Bp: 100/80 delivery, edema.
abdominal  Instruct patient to  Early
surgery report any recognition of
during feelings of possible
current difficulty of adverse effects
breathing or allows for
pregnancy
chest pain, prompt
, uterine dizziness, intervention.
anomaly,
history of nervousness and
cone irregular heart
beats.
biopsy,
 Monitor uterine  Monitor of
maternal contractions, uterine
age including contractions
younger frequency and provides
than 20 or domain. evidence of
older than effective
therapy.
age 35.
Collaborative:
 Obtain diagnostic  Urine, vaginal,
studies including and cervical
complete blood cultures help to
count, rule out
hemoglobin and infection as a
hematocrit, urine, causative factor
vaginal ang for preterm
cervical cultures labor.
as ordered.