NURSING CARE PLAN – Abortion

ASSESSMENT DIAGNOSI INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATION

S N
SUBJECTIVE: Deficient A miscarriage After 8 hours INDEPENDENT: Changes in blood After 8 hours of
“Dinudugo ako, fluid is any of ·Monitor vital pressure may be nursing
humuhilab ang volume pregnancy that nursing signs, used for rough intervention the
tiyan ko kagabi (isotonic) ends intervention compare with estimate of blood patient was able to
pa, 12 linggo na related to spontaneously the patient’s normal loss. demonstrate
ang excessive before the fetus patient will or Symptomatology improved fluid
ipinagbubuntis blood loss. can survive. demonstrate previous readings. may be useful in balance as
ko” (I am twelve The improved Take blood gauging severity evidenced by
weeks pregnant, World Health fluid pressure or length of stable vital signs,
have had cramping Organization balance as good skin turgor,
and bleeding since when possible. bleeding episode.
defines this evidenced by ·Note patient’s Worsening of and prompt
last night) as
unsurvivable stable vital individual symptoms may capillary refill.
verbalize by the
state signs, physiological reflect continued
patient
as an embryo or good skin response to bleeding or
OBJECTIVE:
fetus weighing turgor, bleeding inadequate fluid
·Delayed
500 and prompt such as changes in replacement.
capillary refill
grams or less, capillary mentation, Reflects
·Restlessnes which typically refill.
s weakness, circulating volume
corresponds to a restlessness, and and cardiac
·Changes in fetal age pallor. response to
mentation (gestational
·V/S taken as ·Measure central bleeding and fluid
age) of venous pressure replacement.
follows 20 to 22 weeks (CVP), if Provides
T: 36.9 ˚C or available. guidelines for fluid
P: 90 less.
R: 19 ·Monitor intake replacement.
Miscarriage and Activity increases
BP: 110/ 70 occurs in about output (I&O), and intra-abdominal
15- correlate with pressure and can
20% of all weight predispose to
recognized changes. further bleeding.
pregnancies, ·Maintain bed
and Fluid replacement
rest.
usually occurs Schedule with isotonic
before the 13th activities to solutions depends
week of provide on the degree and
pregnancy. The undisturbed duration of
actual rest periods. bleeding.
percentage Promotes hepatic
of miscarriages DEPENDENT: synthesis of
is ·Administer coagulation
estimated to be fluids as factors to support
as indicated. clotting.
high as 50% of ·Administer Aids in
all vitamin K. establishing blood
pregnancies, ·Monitor Hb, replacement
since Hct, RBC needs and
many count. monitoring the
miscarriages effectiveness of
occur without therapy.
the
woman ever
having known
she
was pregnant.
Of
those
miscarriages
that occur
before
the eighth
week,
30% have no
fetus
associated with
the
sac or placenta.
This condition
is
called blighted
ovum, and
many
women are
surprised to
learn
that there was
never an
embryo
inside the sac.