Anda di halaman 1dari 3

Assessment Nursing Rationale Planning Intervention Rationale Evaluation

Diagnosis
Subjective:
Activity Preterm labor is After 8hoursof Independent: After rendering
“Gulpi nalang intolerance related defined as nursing proper nursing
nag sakit busog, to muscle or uterine interventions, the  Assess status  Assessment interventions, the
nabatyagan ko cellular contractions patient will use of the client provides a goal was MET.
run nga daw hypersensitivity. occurring after identified and fetus. baseline date The patient was
mamata run ko” 20weeks of techniques to for future able to use
gestation and enhance activity comparisons. identified
Objective: before 37 intolerance. techniques to
•Continued completed weeks  Encourage  Bed rest enhance activity
uterine of gestation. Risk bed rest with relieves intolerance.
contraction. factors include patient in side pressure of the
multiple lying position. fetus on the
• Facial gestation, history cervix.
mask of pain. of previous
preterm labor of
•Irritability. delivery,  Apply  Uterine and
abdominal external fetal
• V/S taken surgery during uterine and monitoring
as follows: current fetal provides
pregnancy, monitoring. evidence of
T:37.3 uterine anomaly, maternal and
P:84 history of cone fetal well-
R:19 biopsy, maternal being.
BP: 100/80 age younger than
20 or older than
age 35.
 Monitor  Maternal pulse
patients vital over 120 beats
signs closely, per minute or
every persistent
15minutes. tachycardia or
tachypnea,
chest pain,
dyspnea and
adventitious
breath sounds
may indicate
impending
pulmonary
edema.

 Instruct  Early
patient to recognition of
report any possible
feelings of adverse effects
difficulty of allows for
breathing or prompt
chest pain, intervention.
dizziness,
nervousness
and irregular
heartbeats.
 Monitor  Monitor of
uterine uterine
contractions, contractions
including provides
frequency and evidence of
domain. effective
therapy.

Collaborative:

 Obtain  Urine, vaginal


diagnostic and cervical
studies cultures help to
including rule out
complete infection as a
blood count, causative
hemoglobin factor for
and preterm labor.
hematocrit,
urine, vaginal
and cervical
cultures as
ordered.

Submitted by: Janella A. Ardamoy BSN-IV January 22, 2018