‫إدارة الشئون األكاديمية والتدريب‬

Academic Affairs and Training Administration

Nursing Care Plan (NCP)

Student Name: Fatimah Talal Alsharif Unit: gyne ER M.R. No: 1 Medical Diagnosis: Abortion

Assessment Nursing Patient Nursing intervention Rationale Evaluation

Diagnosis Centered
(in priority Goals
order)
Subjective:  Fluid volume deficit related Short term: Goals met
Dx
-A change in vital signs may
Patient reported that she to blood loss secondary to after 2 hours of effective nursing -Excessive bleeding stopped
-Monitored vital signs
indicate complications
experienced light spotting over incomplete abortion . intervention: -Patient’s blood volume restored
-Changed peri pad
-A prolonged pad in the perineal
the past two day -Excessive bleeding will be stopped and maintained
-Positioned patient flat in bed on
area may lead to infection
Objective: -Patient blood volume will be
her side -Patient’s blood pressure
-Promotes comfort
- Moderate active bleeding restored maintained above100/60
-Monitored blood loss by weighing
-Weighing the pads isused to
noted in the vaginal vault with -Patient’s blood pressure will be -Patient’s pulse rate maintained
used pads
estimate the blood loss of the
the cervical os open maintained above100/60 below 100 bpm
Tx
patient
- Blood clots or tissue on the -Patient’s pulse rate will be
-Administered 1 literof normal saline
-To retore the fluid volume loss
peripad noted maintained below 100 bpm
viaIV
-Used to control excessive
Initial Vital signs: Long term:
-Administered Methergine as
bleeding 
-BP-124/84  after 8 hours of effectivenursing
ordered
-Ability to ambulate independently
-HR-83bpm intervention:
-Assisted patient in ambulation
is needed prior to discharge
-RR-18bpm -Patient blood volume will be
Edx 
-SpO2-100% Supervisor of Training Unit maintained 
-Encouraged patient to drink fluids
-To restore the fluid volume loss

-Front to back motionwill prevent

-Temp-98.3F -Patient blood volume will be
Asma Aldhabi as tolerated
infection
restored
-Educated the patient to clean the
-Helps relieve anxiety and promotes
-Patient’s blood pressure will be
perineal area from front to back
compliance
maintained above100/60
-Educate patient about medications
-Patient’s pulse rate will be
being administered
maintained below 100 bpm