ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:  Activity  Preterm  After 8 hours Independent:  After 8

“Bigla na lang intolerance labor is of nursing hours of
humilab ang related to defined as interventions  Assess status  Assessment nursing
tiyan muscle or uterine , the patient of provides a intervention
ko, parang cellular will use the client and baseline date s, the
contractio
manganganak hypersensitivity identified fetus. for future patient was
ako” (I felt a
ns techniques comparisons. able to use
sudden occurring to enhance identified
contraction, I after 20 activity  Encourage bed  Bed rest techniques
thought weeks of intolerance rest with patient relieves to enhance
I am in labor)
as
gestation in side lying pressure of the activity
verbalized by
patient.
and before position. fetus on the intolerance
37 cervix.
completed
weeks of  Apply external  Uterine and
Objective:
gestation. uterine and fetal fetal monitoring
monitoring. provides
Continued Risk
evidence of
uterine factors maternal and
contraction. include fetal well being.
multiple
Facial mask geatation,  Monitor  Maternal
of pain.
history of patient’s pulse
Irritability.
previous vital signs over 120 beats
preterm closely, every 15 per minute or
labor of minutes. persistent
delivery, tachycardia or
abdominal tachypnea,
chest pain,
surgery
dyspnea and
during adventitious
current breath sounds
pregnancy
, uterine may indicate
anomaly, impending
history of pulmonary
cone edema.
biopsy,
 Instruct patient  Early
maternal to recognition of
age report any possible
younger feelings of adverse effects
than 20 or difficulty of allows for
older than breathing or prompt
age 35. chest pain, intervention.
dizziness,
nervousness and
irregular heart
beats.

 Monitor uterine  Monitor of

contractions, uterine
including contractions
frequency and provides
domain. evidence of
effective
Collaborative: therapy.
 Obtain
diagnostic  Urine,
studies including vaginal,
complete blood and cervical
count, cultures help to
hemoglobin and rule out
hematocrit, urine, infection as a
vaginal ang causative factor
cervical cultures for preterm
as ordered. labor.