Student Nurses’ Community

NURSING CARE PLAN – Spontaneous Abortion

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
Deficient fluid After 8 hours of INDEPENDENT: After 8 hours of
“Dinudugo ako, volume A miscarriage nursing • Monitor vital signs, • Changes in blood nursing
humuhilab ang (isotonic) (spontaneous intervention the compare with pressure may be intervention the
tiyan ko kagabi related to abortion) is any patient will patient’s normal or used for rough patient was able to
pa, 12 linggo na excessive pregnancy that demonstrate previous readings. estimate of blood demonstrate
ang blood loss. ends improved fluid Take blood pressure loss. improved fluid
ipinagbubuntis spontaneously balance as when possible. balance as
ko” (I am twelve before the fetus evidenced by • Note patient’s • Symptomatology evidenced by
weeks pregnant, can survive. The stable vital signs, stable vital signs,
have had cramping individual may be useful in
World Health good skin turgor, physiological gauging severity good skin turgor,
and bleeding since
Organization and prompt response to bleeding or length of and prompt
last night) as
defines this capillary refill. such as changes in bleeding episode. capillary refill.
verbalize by the
patient unsurvivable state mentation, Worsening of
as an embryo or weakness, symptoms may
fetus weighing 500 restlessness, and reflect continued
OBJECTIVE: grams or less, pallor. bleeding or
which typically inadequate fluid
• Delayed corresponds to a replacement.
fetal age
capillary refill
(gestational age) of • Measure central • Reflects
• Restlessnes
20 to 22 weeks or venous pressure circulating volume
s less. Miscarriage
• Changes in (CVP), if available. and cardiac
occurs in about 15- response to
mentation 20% of all bleeding and fluid
recognized replacement.
• V/S taken as pregnancies, and
follows usually occurs
• Monitor intake and • Provides
before the 13th
output (I&O), and guidelines for fluid
T: 36.9 ˚C week of
correlate with weight replacement.
P: 90 pregnancy. The
R: 19 changes.
actual percentage
BP: 110/ 70 • Maintain bed rest. • Activity increases
of miscarriages is
Schedule activities to intra-abdominal
estimated to be as
provide undisturbed pressure and can
high as 50% of all
rest periods. predispose to
pregnancies, since
further bleeding.
many miscarriages
Student Nurses’ Community

occur without the DEPENDENT:

woman ever • Administer fluids as • Fluid replacement
having known she indicated. with isotonic
was pregnant. Of solutions depends
those miscarriages on the degree and
that occur before duration of
the eighth week, bleeding.
30% have no fetus • Administer vitamin K. • Promotes hepatic
associated with the synthesis of
sac or placenta. coagulation
This condition is factors to support
called blighted clotting.
ovum, and many • Monitor Hb, Hct, RBC • Aids in
women are count. establishing blood
surprised to learn replacement
that there was needs and
never an embryo monitoring the
inside the sac. effectiveness of
therapy.