assessment

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:
·Delayed
capillary refill
·Restlessnes
s
·Changes in
mentation
·V/S taken as
follows
T: 36.9 ˚C
P: 90
R: 19
BP: 110/ 70

Diagnosis

Deficient

fluid

volume

(isotonic)

related to

excessive

blood loss
inference

A miscarriage

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 15-

planning

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

intervention

NDEPEND

ENT:

·Monitor

vital signs,

compare

with

patient’s

normal or

previous
readings.

Take blood

pressure

when

possible.

·Note

patient’s

individual

physiologic

al

response to

bleeding

such as

changes in

mentation,

weakness,

restlessnes

s, and

pallor.

·Measure

central

venous

pressure

rationale

·Changes in

blood

pressure may be

used for rough

estimate of blood

loss.

·Symptomatolog

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
evaluation

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.