Date/Time

Cues

Need

Nursing Diagnosis

Goals of Care

Nursing Interventions
1.Monitor vital signs, FHT and uterine contractions serves as a baseline data. Any deviation may indicate complications.

Evaluation

J U N E 20 2012 @ 7 am Subjective: patient verbalized gikapoy na ko cgeg higda. Kung dili ko muhigda , mulingkod ko. Pero diri lang pud kutob. Dili ko ka lakaw lakaw.

A C T I V I T Y

Impaired physical mobility related to prescribed movement restriction secondary to preterm labor Preterm labor is a labor that occurs before the end of 37 weeks of gestation. A woman who is in preterm labor is usually admitted first in the hospital and placed on bed rest to relieved the pressure of the fetus on the cervix. Following initial therapy, women in preterm labor can be safely cared at home as long as

At the end of my 8 hours span of care, the patient will be able to:

Goal Met At the end of my 8 hours span of care, the patient was able to: a. Verbalized Dapat jud maghigda o mu lingkod lang ko diria . Tiison lang nako ni kay para ma ni sa akong baby. Basin sayo kaau mugawas ang akong anak pati kinabuhi nya manganib pa.

a. Verbalized understanding of the situation or risk factors and of individual treatment 2. Assist client on ADLs and regimen b. Perform ADLs without exerting much effort c. Maintain good skin integrity
repositioning on regular schedule

E X C

Aids in conservation of energy and prevent bed sores. 3. Instruct to increase oral fluid intake To increase hydration and to aid to stop contractions

Objectives: -33 weeks AOG -fundic height of 23 cm -LMP: Nov. 1, 2011 -EDC: Aug. 8,

E R C I S E

b. Patient asked assistance during 4. Place patient on a urination and BM.

comfortable position

2012 -(+) irregular uterine contractions -G1P0 -CBR without BRP -Isoxuprine HCL itab q6

they can dependably remain on almost complete bed rest , drink enough fluid to remain hydrated and take an oral tocolytic drug.

Semi-fowlers promotes lung expansion. Sidelying prevent hypotension. 5. Provide safety Prevent injuries that may aggravate patients condition 6. Provide a calm environment To provide patient to have adequate sleep and rest 7. Educate client about the situation and about the treatment regimen Client will be able to gain knowledge and understanding about the situation and treatment required. Client participation may also be attain. 8. Maintain CBR

c. Absence of bed sores.

Kimberly 'Dove' L. Albinda, St. N

without BRP Increase movement will increase the demand for O2 9. Administer prescribed medication Prevent preterm labor and stop contractions