ASSESSMENT DIAGNOSIS BACKGROUND KNOWLEDGE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Anticipatory A pregnancy suddenly ended After 8 Assess the reaction of To determine the feelings of After 8 hours of nursing
“I’m so sad my grieving r/t loss of is not an uncommon hours of patient and support the client and of the significant intervention, the patient
baby is gone, I feel pregnancy, cause experience for many women. nursing person. other. and her husband
that my husband of abortion and Many facets of grief often interventio verbalized their grief and
hates me so future accompany loss including n the Provide information To lessen confusion of patient acknowledged that the
much” as childbearing . emotional turmoil, confusion, patient and regarding current status, regarding the loss, to clarify grieving process lasts
verbalized by the shock, disbelief, guilt, fear, her as needed. and to avoid blame. several months.
client. depression, anger, stress, husband
frustration, disappointment. will Encourage the patient To relieve emotions, sharing of
Because many verbalize to discuss feelings about feelings to father may
Objective: women, even planned grieve and the loss of the baby and encourage support from each
- Vital signs: pregnancies, feel some acknowled include effects on other.
T: 36.5 ambivalence initially, guilt is ge that the relationship with the
P: 80 also a common emotion. grieving father.
R: 20 These feelings may be even process
BP: 110/80 stronger for women who lasts Acknowledge the loss The grieving period following a
were negative about their several and allow grieving. miscarriage usually lasts 6 to 24
- Appears sad pregnancies. months. months.

Listen sympathetically To offer psychological support

to their concerns. for the mother.

Providing time alone for Providing privacy will

the couple to discuss encourage them to verbalize
their feelings. further their concerns.

Discuss the prognosis To inform important matters

of the future about future pregnancies so
pregnancies. they will have informed choices
and smarter decisions.
 ASSESSMENT DIAGNOSIS BACKGROUND KNOWLEDGE PLANNING INTERVENTION RATIONALE EVALUATION
Objective: Fluid volume deficit Hydatidiform Mole / Molar After 8 hours - Assess skin turgor To determine indication of After 8 hours
O> Urinalysis test r/t elevated levels of Pregnancy (H-Mole) is a of nursing and moisture of hydration status/ degree of of nursing
for hCG revealed human Chorionic developmental anomaly of the intervention mucous membranes deficit. intervention,
positive, Gonadotropin (hCG)
from the proliferating placenta, resulting in the client will client
UTZ revealed trophoblasts proliferation & degeneration of display - Monitor vital signs. To have a baseline data, reflects displayed
multiple small chorionic villi w/c develops into a adequate fluid Evaluate peripheral adequacy of circulating volume. adequate
cystic structures, grape like clusters of vesicles. The balance as pulses, capillary refill fluid balance
negative for fetal most common case of Hmole is a evidenced by: To determine decreasing renal as evidenced
parts and also for lesion anteceding choriocarcinoma. output and concentration of by:
fetal heart beat. - Monitor I&O.
1. Stable vital Include all output urine suggest developing
signs. sources (e.g., dehydration and need for fluid 1. Stable vital
2. Moist emesis, diarrhea replacement. signs.
mucous 2. Moist
membranes. To sensitively measure mucous
3. Skin turgor fluctuations in fluid balance. membranes.
less than 1 - Weigh daily 3. Skin turgor
sec. To identify early problems that less than 1
4. Capillary may occur as a result of cancer), sec.
refill of less allows for prompt intervention. 4. Capillary
than 2 secs. - Observe for refill of less
bleeding tendencies; To compensate with the fluid
5. Adequate than 2 secs.
Note the amount,
urine output. volume deficit problem 5. Adequate
lochia/color of the
vaginal discharge urine output.
For the vomiting episodes.

- Encourage increase To prevent unnecessary energy

fluid intake as
expenditure related to vomiting
tolerated
(as may trigger) and bleeding
- Give ice chips on (loss of blood/RBC)
mouth

- Encourage rest