- Acute Pain related to Uterine contractions as evidenced by Reports of pain and increased Muscle tension
- Anxiety related to Situational crisis and a perceived threat to the fetus and self as evidenced by expresses tension and Inability to concentrate
- Risk for Injury related to early labor and delivery and delivery of premature infant as evidenced by risk for respiratory distress syndrome, necrotizing enterocolitis and Premature baby
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Expressions of pain, such as crying Unpleasant feeling (such as a prick, burn, or ache) Objective Data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns | Acute Pain related to Uterine contractions as evidenced by Reports of pain and increased Muscle tension | Patient will report relief from contractions. Patient will demonstrate interventions to help reduce contractions and discomfort. | 1. Place the patient in a lateral recumbent position. A lateral recumbent position promotes patient comfort and placental blood circulation by increasing venous return. 2. Encourage relaxation techniques. Anxiety from preterm labor can aggravate the patient’s discomfort. Relaxation techniques like deep breathing and meditation can calm the patient and significantly reduce pain. 3. Encourage comfort measures. A patient in pain due to premature uterine contractions can greatly benefit from comfort measures like a heating pad or massage to reduce pain. 4. Reduce strenuous activity. While strict bedrest is not recommended, reducing strenuous activities can reduce premature uterine contractions, promote comfort, and further delay the early delivery of the baby. | Patient reported relief from contractions. Patient demonstrated interventions to help reduce contractions and discomfort. |
| Subjective Data: Feeling nervous Verbalizing a sense of impending danger Difficulty controlling one’s worrying Objective Data: -Restlessness and tense appearance -Tachycardia -Tachypnea -Hyperventilation -Diaphoresis -Trembling/tremors -Weakness or tiredness -Difficulty concentrating -Difficulty sleeping -GI distress | Anxiety related to Situational crisis and a perceived threat to the fetus and self as evidenced by expresses tension and Inability to concentrate | Patient will demonstrate interventions that can reduce anxiety. Patient will verbalize understanding of the current situation and adhere to the plan of care. | 1. Educate the patient about the management of preterm labor. A better understanding of what is happening and interventions performed can reduce the patient’s anxiety and promote adherence to the treatment regimen. 2. Build a therapeutic relationship. The nurse is often a source of emotional support for the mother and can create a healthy and safe environment. Remain calm and professional to keep the patient’s anxiety low. 3. Encourage the patient to use relaxation techniques. Relaxation can significantly reduce anxiety levels, especially for those experiencing preterm labor. Instruct on breathing techniques, and create a calming environment through soothing music, back rubs, and dim lighting. 4. Provide honest and accurate answers about the situation. This will help the patient and family understand what is happening and significantly reduce stress and anxiety. 5. Assist the patient in planning for delivery. Preterm labor may or may not result in delivery. Allowing the patient to be a part of the planning and providing choices (if applicable) can help prepare the patient in case delivery is imminent. | Patient demonstrated interventions that can reduce anxiety. Patient verbalized understanding of the current situation and adhere to the plan of care. |
| Subjective Data: Expresses concerns over baby and self Objective Data: -Risk for respiratory distress syndrome, necrotizing enterocolitis -Premature baby -Chances of Neonatal death | Risk for Injury related to early labor and delivery and delivery of premature infant as evidenced by risk for respiratory distress syndrome, necrotizing enterocolitis and Premature baby | Patient will adhere to the treatment regimen and reach at least 37 weeks gestation. Patient will deliver a preterm infant without any complications. | 1. Educate the patient about interventions that can help prevent the progression of preterm labor and early delivery. When the patient knows and understands what is happening, she will be more likely to adhere to the interventions and treatment regimen. 2. Administer tocolytics as indicated. Medications like magnesium sulfate and other tocolytics can help reduce uterine contractions. 3. Encourage bed rest. If hospitalized, bed rest may be prescribed to reduce pressure on the cervix and slow preterm delivery. The mother should only get up to go to the bathroom. Blood clots are a concern with bed rest so ensure sequential compression devices are on the lower legs while in bed. 4. Administer steroid therapy as needed. Steroids may be provided to help reduce respiratory distress syndrome, necrotizing enterocolitis, and neonatal death in premature infants, as this drug can enhance the formation of surfactant in the fetal lungs. | Patient adhered to the treatment regimen and reach at least 37 weeks gestation. Patient delivered a preterm infant without any complications. |