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Student Nurses’ Community NURSING CARE PLAN – Spontaneous Abortion ASSESSMENT
DIAGNOSIS
INFERENCE
PLANNING
INTERVENTION
RATIONALE
EVALUATION
SUBJECTIVE: “Dinudugo ako, humuhilab ang tiyan ko kagabi pa, 12 linggo na ang ipinagbubuntis ko” (I am twelve weeks pregnant, have had cramping and bleeding since last night ) as
verbalize by the patient
OBJECTIVE: •
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Delayed capillary refill Restlessnes s Changes in mentation V/S taken as follows T: 36.9 ˚C P: 90 R: 19 BP: 110/ 70
Deficient fluid volume (isotonic) related to excessive blood loss.
A miscarriage (spontaneous abortion) is any pregnancy that ends spontaneously before the fetus can survive. The World Health Organization defines this unsurvivable state as an embryo or fetus weighing 500 grams or less, which typically corresponds to a fetal age (gestational age) of 20 to 22 weeks or less. Miscarriage occurs in about 1520% of all recognized pregnancies, and usually occurs before the 13th week of pregnancy.. The pregnancy actual percentage of miscarriages is estimated to be as high as 50% of all pregnancies, since many miscarriages
After 8 hours of nursing intervention the patient will demonstrate improved fluid balance as evidenced by stable vital signs, good skin turgor, and prompt capillary refill.
INDEPENDENT: • Monitor vital signs, compare with patient’s normal or previous readings. Take blood pressure when possible. Note patient’s individual physiological response to bleeding such as changes in mentation, weakness, restlessness, and pallor. •
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Measure central venous pressure (CVP), if available.
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Monitor intake and output (I&O), and correlate with weight changes. Maintain bed rest. Schedule activities to provide undisturbed rest periods.
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Changes in blood pressure may be used for rough estimate of blood loss. Symptomatology may be useful in gauging severity or length of bleeding episode. Worsening of symptoms may reflect continued bleeding or inadequate fluid replacement. Reflects circulating volume and cardiac response to bleeding and fluid replacement. Provides guidelines for fluid replacement. Activity increases intra-abdominal pressure and can predispose to further bleeding.
After 8 hours of nursing intervention the patient was able to demonstrate improved fluid balance as evidenced by stable vital signs, good skin turgor, and prompt capillary refill.
Student Nurses’ Community
occur without 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 or placenta.. This condition is called blighted ovum,, and many ovum women are surprised to learn that there was never an embryo inside the sac.
DEPENDENT: Administer fluids as indicated. •
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Administer vitamin K.
Monitor Hb, Hct, RBC count.
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Fluid replacement with isotonic solutions depends on the degree and duration of bleeding. Promotes hepatic synthesis of coagulation factors to support clotting. Aids in establishing blood replacement needs and monitoring the effectiveness of therapy.
