ASSESSMENT DIAGNOSIS

Subjective: Parang humihilab ang tiyan ko, as verbalized by the client. Objective: Activity intolerance related to muscle or cellular hypersensitivity.

y Continued uterine contraction 3 times in 30 minutes y Facial grimace y VS taken as follows: T-36.5C PR- 92 bpm BP- 120/70 mmHg RR- 20 cpm

INFERENCE Preterm labor is defined as uterine contractio ns occurring after 20 weeks of gestation and before 37 completed weeks of gestation. Risk factors include multiple geatation, history of previous preterm labor of delivery, abdominal surgery during current pregnancy , uterine anomaly,

PLANNING INTERVENTION
After 8 Independent: hours y Assess status of of nursing the client and interventions fetus. , the patient will use identified techniques y Encourage bed to enhance rest with patient in activity side lying intolerance. position. y Apply external uterine and fetal monitoring.

RATIONALE
y Assessment provides a baseline date for future comparisons. y Bed rest relieves pressure of the fetus on the cervix. y Uterine and fetal monitoring provides evidence of maternal and fetal well being. y Maternal pulse over 120 beats per minute or persistent tachycardia or tachypnea, chest pain, dyspnea and adventitious breath sounds may indicate

EVALUATION

Monitor patients vital signs closely, every 15 minutes.

history of cone biopsy, maternal age younger than 20 or older than age 35.

impending pulmonary edema. y Instruct patient to report any feelings of difficulty of breathing or chest pain, dizziness, nervousness and irregular heartbeats. Monitor uterine contractions, including frequency and domain. y Early recognition of possible adverse effects allows for prompt intervention. y Monitor of uterine contractions provides evidence of effective therapy. y Urine, vaginal, and cervical cultures help to rule out infection as a causative factor for preterm labor.

Collaborative: y Obtain diagnostic studies including complete blood count, hemoglobin and hematocrit, urine, vaginal ang cervical cultures as ordered.