Preterm Labor Nursing Concept Map

Preterm Labor
Multiple gestation, intrauteine grewth restrktion,
gestational diabetes, preeclampsla,
age extremes, stress, substarce abuse,
anemia, trauma, STts, infection, history of preterm labor
Definition
Nursing Diagnoses
Risk for fetal impained gas exchange r/t possible ccrd compressicn,
ineffective tissue perfusion r/t side effects of Magnesium Sulfate,
fiuid volume imbalance r/t administration of Magnesium Sulfate,
constipation r/t decreased mobillity and medication,
pain r/t preterm labor cortracticns, fear r/t unkncwn cutcome of birtth, deficiert
knowledge /t lack of information of problems associated with muitiple gestations,
Assessment
Assessment completed 9-12-D7. Patient was awake and alert, refiexes were p+2-
Temperature - 36-4 c, pulse - 79, blocd pressure - 12/69, respirations - 16
patient was negative for edema and homans sign, SCD 's were on.
Lungs were cleae to auscultation billaterally, Respirations were even and unlabored.
Abdomen was soft and bowel sounds were nonmoactive, urine, Vision was Clear.
Mernbranes were intavt and negative for vaginal bleeding.
Fetal heart rates were 'a'-135 and 'b'-135 bpm with good variabillity and a-ccerations,
Contractions were two per hour at 40 seonds in length with mildd irtensity (nose)-
Interventions
Assessments
monitors
Lob Tests.
Medicaltions
Assess
Side effects,
therapeutic effects,
vital signs,
contractions
Goals
-patient will have -c2 contractions
per hour with a lenhth <45 seconds
aftre 24 hours.
-patient panin level will remain under
5/10 until delivery,
patient will remain free from Dvt's
until discharge.
patient will eat>50% of meals until discharge.
-patient will contirue to have 1 BM
per day untill discharge
Outcomes
-patient' will remain inutero
as long as possible,
-patient's pain will be manageable,
-patient will maintain good blood
circullation-
-patient will malrtain adequate
nutrition,
-patient will mairtain adequate
GI motillty,
Matemal
Fetal
Blood pressure: 123/69
pulse:79
Tocodynarometer:x2 per hour
40 seconds in length
Fetal heart rate
normal: 110 -160 bpm
Twin a & B:135 bpm
Speculation exam
Blood tests
Urinalysis
Uitrasound
Cervical length
Fetal fibronectin (FN)
Goals
Diagnosed
Symptoms
Abdomanal pain,
back pain, diarrhea
peivic pain, cramps,
vaginal bieeding,
vaginal discharge,
pelvic pressure,
urinary frequency,
Bishop's score,
Cervical length,
Fetal fibronectin (fFN) levels,
Electroric monitoring
Labor that begins before
completion of 37 weeks but
after 20 weeks from
yhe last menstrual period
Risks for
89