ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM

Subjective: A miscarriage is any STO: Dx: STO:

pregnancy that end
"Dinudugo ako, kagabi spontaneously before the
pa " fetus can survive. The
WHO defines this
Objective:
unsurvivable state as an
 Restlessness embryo or fetus weighing
 Edema 500 gram or less which
 Poor skin turgor typically corresponds to a
V/S taken as follows
fetal age of 20-22 weeks or
T: 37.5
less. Miscarriage occurs in
P: 90
all about 15-20% of all
R: 19
BP: 110/70 recognized pregnancies,
and usually occurs before
Nursing Diagnosis: of 13th week of pregnancy.
Within 8 hours of effective  Monitor vital signs  Changes in blood pressure (Goal Met)
nursing interventions, the may be used rough estimate
patient will be able to: of blood loss Within 8 hours of
effective nursing
 Note patients individual
a) Verbalize  Symptomatology may be interventions, The
physiological response to
understanding of used in gauging severity or patient verbalized
bleeding such as changes in
causative factors length of bleeding episode. understanding of
mentation, weakness,
and purpose of causative factors
restlessness and pallor
individual and purpose of
therapeutic individual
 To be used as preference,
interventions and therapeutic
 Assess skin turgor and oral reason for admission.
medication. interventions and
mucous membranes for signs
medication
LTO: of dehydration

Tx:  Early identification of risk

Deficient fluid volume SOURCE: Within 24-48 hours of
factors can decrease
(hypertonic) related to World health organization effective nursing LTO:
 Monitor intake and output and occurrence and severity of
excessive bleeding interventions, the patient
correlate with weight changes complications associated (Goal Met)
will:
with hypovolemia
a) Client will Within 24 hours of
maintain fluid effective nursing
volume at a interventions, the
This helps the skin stay healthy
functional level as patient’s
and prevents bedsores.
evidenced by
 Change the position will maintain fluid
individually Aids inestablishing
frequently, turn side to side volume at a
adequate bloodreplacementneeds
every 2 hours if necessary functional level as
hemoglobin, andmonitoring theeffectiveness
evidenced by
hematocrit oftherapy
individually
laboratory results,  Monitor Hb, Hct, RBCcount Activity increases intra-abdominal adequate
stable adequate pressure and can predispose to hemoglobin,
urine output, good Edx: further bleeding hematocrit
uterine laboratory results,
 Maintain and rest schedule To assess the water intake and
contractility, good activities to provide stable adequate
skin turgor and hydration state among pregnant urine output, good
undisturbed rest period
capillary refill women uterine
 Discuss factors related to
occurrence of dehydration . contractility, good
skin turgor and
capillary refill
 Assessed ability to perform
activities of daily living.

 Assess severity of depression.

Tx:

 Encouraged client to “cry out”

grief to and talk about feelings
of anger, sadness, and guilt.

 Help client recognize that

although sadness will occur at
intervals for the rest of her life,
it will become bearable.
 Strengthen the patient’s efforts
to go on with his or her life and
normal routine.

Edx:

 Encourage client to make

choices about daily living and
the home environment that
acknowledge the loss

 Encourage client to interact with

the support system at defined
intervals.

 Encouraged verbalization of
feelings