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Nursingcrib.com NURSING CARE PLAN - Spontaneous Abortion

Nursingcrib.com NURSING CARE PLAN - Spontaneous Abortion

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Published by deric
a care plan for patients suffering from spontaneous abortion or miscarriage
a care plan for patients suffering from spontaneous abortion or miscarriage

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Categories:Types, Research
Published by: deric on Jun 01, 2009
Copyright:Attribution Non-commercial

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12/16/2014

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NURSING CARE PLAN– Spontaneous AbortionASSESSMENTDIAGNOSISINFERENCEPLANNINGINTERVENTIONRATIONALEEVALUATION
SUBJECTIVE:“Dinudugo ako,humuhilab angtiyan ko kagabipa, 12 linggo naangipinagbubuntisko” (
I am twelveweeks pregnant,have had cramping and bleeding sincelast night 
 )
asverbalize by thepatientOBJECTIVE:
Delayedcapillary refill
Restlessness
Changes inmentation
V/S taken asfollowsT: 36.9 ˚CP: 90R: 19BP: 110/ 70Deficient fluidvolume(isotonic)related toexcessiveblood loss.A miscarriage(
spontaneousabortion
) is anypregnancy thatendsspontaneouslybefore thefetuscan survive. TheWorld HealthOrganization defines thisunsurvivable stateas anembryoor fetus weighing 500grams or less,which typicallycorresponds to afetal age(gestational age) of 20 to 22 weeks or less. Miscarriageoccurs in about 15-20% of allrecognizedpregnancies, andusually occursbefore the 13thweek of pregnancy. Theactual percentageof miscarriages isestimated to be ashigh as 50% of allpregnancies, sincemany miscarriagesAfter 8 hours of nursingintervention thepatient willdemonstrateimproved fluidbalance asevidenced bystable vital signs,good skin turgor,and promptcapillary refill.INDEPENDENT:
Monitor vital signs,compare withpatient’s normal or previous readings.Take blood pressurewhen possible.
Note patient’sindividualphysiologicalresponse to bleedingsuch as changes inmentation,weakness,restlessness, andpallor.
Measure centralvenous pressure(CVP), if available.
Monitor intake andoutput (I&O), andcorrelate with weightchanges.
Maintain bed rest.Schedule activities toprovide undisturbedrest periods.
Changes in bloodpressure may beused for roughestimate of bloodloss.
Symptomatologymay be useful ingauging severityor length of bleeding episode.Worsening of symptoms mayreflect continuedbleeding or inadequate fluidreplacement.
Reflectscirculating volumeand cardiacresponse tobleeding and fluidreplacement.
Providesguidelines for fluidreplacement.
Activity increasesintra-abdominalpressure and canpredispose tofurther bleeding.After 8 hours of nursingintervention thepatient was able todemonstrateimproved fluidbalance asevidenced bystable vital signs,good skin turgor,and promptcapillary refill.

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