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Sultan - NCP 1 (Preterm Labor)

The nursing care plan addresses a patient experiencing activity intolerance due to muscle or cellular hypersensitivity. The objectives are for the patient to apply identified ways to improve activity intolerance after 8 hours of nursing interventions. Interventions include assessing the patient and fetus, encouraging bed rest, applying external monitoring, close monitoring of vital signs every 15 minutes, instructing the patient to report difficulty breathing or irregular heartbeats, and monitoring uterine contractions. The rationale is for gathering baseline data, relieving pressure on the cervix, determining maternal and fetal well-being, and allowing for prompt intervention if adverse effects occur.

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Johanisa Sultan
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103 views

Sultan - NCP 1 (Preterm Labor)

The nursing care plan addresses a patient experiencing activity intolerance due to muscle or cellular hypersensitivity. The objectives are for the patient to apply identified ways to improve activity intolerance after 8 hours of nursing interventions. Interventions include assessing the patient and fetus, encouraging bed rest, applying external monitoring, close monitoring of vital signs every 15 minutes, instructing the patient to report difficulty breathing or irregular heartbeats, and monitoring uterine contractions. The rationale is for gathering baseline data, relieving pressure on the cervix, determining maternal and fetal well-being, and allowing for prompt intervention if adverse effects occur.

Uploaded by

Johanisa Sultan
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective cues: Activity intolerance After 8 hours of Independent: After 8 hours of


r/t muscle or cellular rendering nursing rendering nursing
“Bigla na lang po ako  Assess the To gather baseline
hypersensitivity. interventions, the interventions, the
nakaramdam ng status of the data for future
patient will apply patient was able to
pagsakit at paghilab ng client and fetus. references.
identified ways to apply identified
aking tiyan. Masakit na
improve activity ways to improve
tila ba ako’y  Encourage bed
intolerance. activity intolerance.
manganganak na.” (I rest with Bed rest relieves
suddenly felt pain and patient is side pressure of the
contractions in my lying position. fetus on the cervix.
Objectives met.
abdomen. It was so
painful that I thought I  Apply external
To determine
am to labor.) As uterine and
status of both
verbalized by the fetal maternal and fetal
patient. monitoring. well-being.
Objective cues:
 Close
 Facial grimace monitoring of Maternal pulse
 Irritability patient’s vital over 120 bpm or
 Continued signs every after persistent
uterine 15 minutes. tachycardia or
contraction bradypnea, chest
pain, dyspnea and
adventitious breath
sounds may
Vital signs were indicate pulmonary
recorded as: edema.
T:
 Instruct patient
to report any
PR: feelings of Early recognition of
difficulty possible adverse
RR: effects allows for
breathing, chest
BP: pain, dizziness, prompt
nervousness intervention.
O2 Sat: and irregular
heartbeats.

 Monitor uterine
contractions,
including Monitor of uterine
frequency and contractions
domain. provides evidence
of effective
therapy.
Collaborative:

 As ordered,
obtain
diagnostic tests
such as a Urine, vagina, and
complete blood cervical cultures
count, help to rule out
infection as a
hemoglobin,
causative factor for
and hematocrit,
preterm labor.
as well as urine,
vaginal, and
cervical
cultures.

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