Student Nurses’ Community

NURSING CARE PLAN – Spontaneous Abortion

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
Deficient fluid After 8 hours of INDEPENDENT: After 8 hours of
“Dinudugo ako, volume A miscarriage nursing  Monitor vital signs,  Changes in blood nursing
humuhilab ang (isotonic) (spontaneous intervention the compare with pressure may be intervention the
tiyan ko kagabi related to abortion) is any patient will patient’s normal or used for rough patient was able
pa, 12 linggo na excessive pregnancy that demonstrate previous readings. estimate of blood to
ang blood loss. ends improved fluid Take blood pressure loss. demonstrate
ipinagbubuntis spontaneously balance as when possible. improved fluid
ko” (I am twelve before the fetus evidenced by  Note patient’s  Symptomatology balance as
weeks pregnant, can survive. The stable vital signs, individual may be useful in evidenced by
have had cramping good skin turgor, stable vital signs,
and bleeding since
World Health physiological gauging severity
Organization and prompt response to bleeding or length of good skin turgor,
last night) as
defines this capillary refill. such as changes in bleeding episode. and prompt
verbalize by the
unsurvivable state mentation, Worsening of capillary refill.
patient
as an embryo or weakness, symptoms may
fetus weighing 500 restlessness, and reflect continued
OBJECTIVE: grams or less, pallor. bleeding or
which typically inadequate fluid
 Delayed corresponds to a replacement.
capillary refill fetal age
(gestational age) of  Measure central  Reflects
 Restlessness
20 to 22 weeks or venous pressure circulating volume
 Changes in
less. Miscarriage (CVP), if available. and cardiac
mentation
occurs in about 15- response to
20% of all bleeding and fluid
 V/S taken as recognized replacement.
follows pregnancies, and
usually occurs  Monitor intake and  Provides
T: 36.9 ˚C before the 13th output (I&O), and guidelines for fluid
P: 90 week of correlate with weight replacement.
R: 19 pregnancy. The changes.
BP: 110/ 70 actual percentage  Maintain bed rest.  Activity increases
of miscarriages is Schedule activities to intra-abdominal
estimated to be as provide undisturbed pressure and can
high as 50% of all rest periods. predispose to
pregnancies, since further bleeding.
many miscarriages
Student Nurses’ Community

occur without the DEPENDENT:

woman ever  Administer fluids as  Fluid replacement
having known she indicated. with isotonic
was pregnant. Of solutions depends
those miscarriages on the degree and
that occur before duration of
the eighth week, bleeding.
30% have no fetus  Administer vitamin K.  Promotes hepatic
associated with the synthesis of
sac or placenta. coagulation
This condition is factors to support
called blighted clotting.
ovum, and many  Monitor Hb, Hct, RBC  Aids in
women are count. establishing blood
surprised to learn replacement
that there was needs and
never an embryo monitoring the
inside the sac. effectiveness of
therapy.