BIOGRAPHIC DATA

Name: Mary Ann Ysip

Sex: Female
Age: 39
Civil Status: married
Address: Menzyland Mojon, Malolos Bulacan
Birthday: Dec. 18, 1970
PRESENT HEALTH STATUS
*Chief Complaint: Hypogastric pain
*Date Admitted: August 16, 2009
*Time admitted: 1:00pm
*LMP = March 25, 2009
*AOG =20 weeks and 4 days
*Fundic height is in level of umbilicus
* (+) uterine contractions
PAST HEALTH HISTORY
The client is G3P2 with past two pregnancies in NSVD and full term. No complications were reported. The client has
had myoma in the uterus and the husband said that it was not known by the doctors. The client also had appendectomy
last September 2008. The client has no known familial diseases.

NURSING CARE PLAN

CUES

NURSING
DIAGNOSIS

ANALYSIS

S> She rated her

pain with a scale of 5
of 10.because of the
pain she is feeling
from the hypogastric
region and in pelvis.

Pain related to
uterine
contraction as
evidenced by
report of
discomfort.

Preterm labor refers to

labor that occurs after
the fetus has reached
the period of viability (at
least 20 weeks
gestation but before the
completion of the 37th
wk). Carrying the
pregnancy to term may
be contraindicated if
associated client or
fetal risks outweigh the
risks of delivering a
preterm infant.

> She said that she

felt discomfort/ pain
during contraction.
> Prior to admission,
the client stated that
she sleeps an
average of 8 hours.
The usual sleeping
time is 9pm and the
usual waking time is
5am. The client said
that she has
continuous sleep
that time. But since
the hypogastric pain
she is feeling has
started, her sleep
was interrupted
O> The client is on

GOALS AND
OBJECTIVES

GOAL:
Within the shift the
client report of
discomfort is
minimized.

INTERVENTION

RATIONALE

Independent

discomfort.

Institute bed rest

for client, using
lateral recumbent
position.
Side-lying position
improves uterine
blood flow

Side-lying position
improves uterine
blood flow bed rest
for client, using
lateral recumbent
position, and may
decrease uterine
irritability.

OBJECTIVES:
Within 10 minutes
of nursing
intervention, Mrs.
Ysip will
remember/know
different relaxation
techniques.

Within 10 minutes
of nursing
intervention, Mrs.
Ysips muscle
tension and feeling
of fatigue will be
lessened.

and may decrease

uterine irritability.
Review relaxation
techniques, e.g.,
deep breathing
Helps client refocus
attention,
decreases muscle
exercises,
visualization,
guided imagery,
soft music.
tension, reduces
perception of
discomfort and

Helps client refocus

attention,
decreases muscle
tension, reduces
perception of
discomfort and
promotes sense of
control
promotes sense of
control.
tension, reduces
perception of
discomfort and
Relieves muscle
tension and fatigue.
Touch therapy is

EVALUATION

After the shift

the clients
report of
discomfort is
minimized as
evidenced by
relaxed
appearance and
is resting
appropriately;
with maternal
vital signs within
normal limits.

complete bed rest

and is not physically
active.
> Always seen
sleeping.

Within 10 minutes
of nursing
intervention, Mrs.
Ysip will have
uninterrupted
periods of sleep.

> (+) uterine

contractions
> Facial grimace
> Theres guarding
behavior during
monitoring of FHT.
M>
BP- 110/70
T- 36.5 0C
RR- 21 cpm
PR- 96 bpm

Within 10 minutes
of nursing
intervention, Mrs.
Ysips VS will be
monitored as per
indicated.

promotes sense of
control. (Refer to
ND: Anxiety
[specify
level]/Fear.)
Use nursing
comfort measures
such as changes of
linen and position,
back rub, and
Therapeutic Touch.
Relieves muscle
tension and
Reflects
effectiveness of
interventions.

Within 10 minutes
of nursing
intervention, Mrs.
Ysip will receive
analgesics as per
doctors order.

Provide positioning
and measures to
have uninterrupted
periods for
rest/sleep. Dont
wake up the client
while seen sleeping
unless necessary.

Within 10 minutes
of nursing
intervention, Mrs.
Ysip will receive IV
fluid as per doctors
order.

Monitor maternal
and fetal vital signs.

helps in lessening
pain and level of
anxiety.

Promotes rest,
prevents fatigue,
and may enhance
relaxation.

Reflects
effectiveness of
interventions.

Mild analgesics
decrease muscle
tension and
discomfort.

Hydration may
decrease uterine
activity. Before
beginning drug
therapy, hydration

Collaborative
Administer
analgesics, as
indicated.
Mild analgesics
decrease muscle
tension and

discomfort.
Administer IV
solution or fluid
bolus as indicated

FAR EASTERN UNIVERSITY

Sampaloc Manila

NURSING CARE PLAN

Submitted by:

promotes renal
clearance and
minimizes
hypotension.

ORTEGA, Jamine Joyce

SANTOS, Lazzaro Jo
BSN 128 Group 112

Submitted to:
Mrs. Anita Apostol
August 24, 2009