CUES/EVIDENCES Subjective Verbalized gikuyawan ko, kay murag maliponglipong ra ko kailt:.

. Verbalized naa koy kahadlok pero kailangan man god ko operahan. Objective Increased tension, apprehension, Fear of unspecific consequences irritated

NURSING DIAGNOSIS Anxiety related to situational crisis secondary to blighted ovum

OBJECTIVES Within our 8-hour care the patient will recognize the presence of anxiety as evidenced by. Verbalize awareness of feelings Report anxiety reduced to manageable level Identify the cause of anxiety. Begin to use positive coping strategies to adjust to the situation. Report anxiety reduced to a manageable level

INTERVENTIONS Independent Assess mental status, including mood/affect, comprehension of events and content of thoughts. Acknowledge the clients anxiety. Encourage ventilation of feelings.

RATIONALE

EVALUATION At the end of our 8- hour care the patient will recognize the presence of anxiety as evidenced by: Goal met: Able to verbalize awareness of feelings Identify the cause of anxiety Begin to use positive coping strategies to adjust to the situation by walking around Able to report anxiety reduced to manageable level

Initially, patient may use denial and repression to reduce and filter information that might be overwhelming. Client may need assistance in recognizing reactions. (According to Wiedenbachs the helping art of clinical nursing : a patient as any individual who is receiving help of some kind , be it care institution or advice , from a member of the health profession or from a worker in the field of health ) Conveys a caring attitude. These interventions are soothing and helpful for positive outcomes. Holding the breath and tightening the muscles may influence physiological responses (BP, pulse, and respiration).

Reluctance to express true feelings Lack of involvement in care

Be empathic and non judgmental. Create a restful environment; use guided imagery and relaxation exercises. Provide instruction in breathing and relaxation techniques.

Explain procedures before they are performed, and stay with the client to

A physical presence is reassuring and can increase cooperation

CUES/EVIDENCES Subjective: Verbaized she is feeling well and able to ambulate Objective: Vital Signs: T= 38.50 C P= 82 bpm R= 27 cpm BP= 100/70 mmHg Laboratory Results: WBC: 13.6 cu/mm (5-10 cu/mm) Hematocrit: 39.1 vol%

NURSING DIAGNOS Ris for infection related to possible gestational sac fragment secondary to dilatation and curettage

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

Within the 8 hour nursing care, the client will not Monitor and take vital signs develop infection as evidenced by: V/S within normal range T=36.50C -37.50C PR=60-100 bpm, regular, full bounding RR= 16-20 cpm, Promote proper regular, moderate in hand washing to visitors depth, without use of and health care givers accessory muscles BP=100-140/60-90mmHg
Laboratory results within normal range

Vital signs not within

normal range are signs of infection. (According to Neumans systems model: System Model: nursing intervention focus on retaining or maintaining system stability.)

Hand washing is a firstline defense against infections as it uses flowing water, mechanical action and the antibacterial properties of soap to wash away infectious agents. Premature discontinuation of treatment when client begins to feel well may result in return of infection and potentiate drug-resistant strains. This is for the mobilization of respiratory secretions and prevention of aspiration/respiratory infection

Emphasize necessity of taking antivirals/ antibiotics, as directed (e.g. dosage and length of therapy)

Encourage early ambulation, deep, breathing, coughing, poition changes.

Collaborative: Administer antimicrobials

Antimicrobial drugs prevent infection of wound site by fighting infectious agents.

Risk for bleeding related to subinvolution of the uterus secondary to blighted pregnancy