DIVINA GRACIA VIBAL CIELO BSM-II

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

PATIENT’S DATA Lumbar pain and Abortion is the most Giving midwife Gathering of patient’s Data gathering for Midwife intervention
Name: Patient Jessa slightly vaginal common bleeding intervention to patient data. comparison of past given to patient in
Age: 35 years old bleeding with bright red disorder of early in order to stop and present data. order to stop vaginal
Occupation: Factory color, and no cervical pregnancy. This is the vaginal bleeding, bleeding, improve
worker dilation present on termination of improve lumbar pain Assess patient’s vital Assessment provides a lumbar pain and/or
G1P0 vaginal examination pregnancy before and/or stabilize health signs. baseline for future stabilize health
Chief complaints: may be related to viability that is before condition. comparisons. condition.
Lumbar pain and threatened abortion. 20 weeks gestation
slightly vaginal from LMP or before the After giving midwife Request for laboratory Provides data for After giving midwife
bleeding fetus weighs 500 intervention, the including CBC and evaluation of patient’s intervention, the
LMP grams. patient will report for Urinalysis. health condition and patient was able to
vaginal bleeding and possible complications. report for vaginal
OBJECTIVE DATA: There are types of any signs of bleeding and any signs
Laboratory, diagnostic abortion the elective discomfort. Request and assist for An ultrasound can of discomfort.
tests (vital signs), and and spontaneous. ultrasound document fetal health,
patient’s appearance, Elective abortion is the examination. cervical dilation, and
vaginal examination deliberate termination confirmation of arising
Scant vaginal bleeding, of pregnancy while complication.
bright red in color. spontaneous is the
No present of cervical loss of fetus during Nutrition and health Provides information
dilation on vaginal pregnancy due to teaching. for proper diet and
examination. natural causes. hygiene to improve
maternal and fetal
There are four types of condition.
spontaneous abortion:
threatened, inevitable, Give and inform patient Provides accurate
incomplete, and of medicine to be information of medicine
complete. intake according to to be intake that may
doctor’s prescription: improve maternal and
Threatened abortion Duvadilan, Susten, fetal condition.
refers to the possible Vitamin B complex,
loss of products of Calcium carbonate,
conception. Folic acid, and Ferrous
sulfate.
Inevitable abortion
refers to the loss of the Assess client’s A well-informed client
products of conception knowledge of can participate more
that cannot be threatened abortion. fully in her own care.
prevented.
Assess anxiety level of Relaxation techniques
Complete abortion client over threatened help to decrease
refers to the abortion using anxiety and fear,
spontaneous expulsion relaxation techniques. enhancing feelings of
of the products of control.
conception after the
fetus has died in utero. Instruct patient to avoid Assuming the
strenuous activity. threatened abortion
Incomplete abortion involves a live fetus
refers to the expulsion and presumed
of some parts and placental bleeding.
retention of other parts Instruct patient to have Bed rest relieves
of conceptus in utero. bed rest with left side- pressure of the fetus
lying position until on the cervix. Left side-
three days after lying position
bleeding has stopped. enhances uterine
prefusion.

Advise the patient and The risk of guilt

her partner not to feelings associated
engage in coitus up to with abortion
2 weeks after bleeding immediately after
stopped. intercourse warrant
Encourage patient to abstention and to
have prenatal check- prevent infection and
ups. avoid inducing further
bleeding.

Instruct patient to have To go over any

follow-up visit and/or potential medication
hospitalization if changes and give
condition worsen. additional medical
and/or surgical
intervention.