NURSING CARE PLAN

Assessment
Subjective data:
Nagdurugo ang
aking
sinapupunan as
verbalized by the
patient.
Objective data:
With vaginal
bleeding
With blood
loss of 220ml
With
decreased
RBC
(3.18x1012/L)
(Feb.
14,2012)
Weak in
appearance
With body
malaise

Nursing
Diagnosis
Deficient fluid
volume:
Hypovolemia
related to
increased
vascularity of the
chorionic villi as
evidenced by
vaginal bleeding,
blood loss of 220
ml and decreased
RBC count.

Planning
At the end of the
shift, the patient
will be able to:

Verbalize
understanding
of causative
factors and
purpose of
individual
therapeutic
interventions
and
medication.

Intervention
Independent:
Assess vital
signs, noting
the blood
pressure and
pulse rate.

Change the
position
frequently, turn
side to side
every 2 hours

Demonstrat
if necessary.
e behaviors to
monitor and
Discuss factors
correct deficit,
related to
as indicated.
occurrence of
deficit as
individually
appropriate.

Rationale
These
changes in
vital signs are
associated
with fluid
volume loss
and/ or
hypovolemia.
To reduce
pressure on
fragile skin
and tissues.

Early
identification
of risk factors
can decrease
occurrence
and severity of
complications
associated
with
hypovolemia.

Evaluation
Goals met: The
patient verbalized
understanding of
causative factors
and purpose of
individual
therapeutic
interventions and
medication. The
patient also
demonstrated
behaviors to
monitor and
correct deficit
indicated.

 Measure the
amount of
blood loss.

To note how
blood loss
affects the
patients fluid
volume status.

Explain the
drug which is
ordered to the
patient and
how it takes its
function.

To informed
the patient for
the possible
therapeutic
effects of the
drug.

Instruct the
patient to
maintain at
bed rest.

To prevent the
recurrence of
vaginal
bleeding
associated
with frequent
motion/
movements.

Provide
Intravenous
(IV) fluids as
ordered by the
physician.

To replace and

conserve
blood volume
contrary to the
blood loss
caused by
vaginal
bleeding.