EASTER COLLEGE

DEPARTMENT OF NURSING
Easter School Road, Guisad, Baguio City

In Partial Fulfillment of the

Course Requirements
In RLE

Submitted by:
Lody Lean C. Cruz

Submitted to:
David Jezer Reyes

Date of Submission:
December 24, 2022
Clinical Area/Hospital: OB/GYNE (Benguet General Hospital) Dates and Shift Time: December 19-21 / 7-3
Name of Student: Lody Lean C. Cruz Year, Group, and Sub Group: 3E-4
Name of Patient: Judy Ann B. Saltin
Admitting Diagnosis: G4P4 Pregnancy Uterine 27-28 Weeks AOG IUTP
Date and Time Admitted: December 19, 2022 at 6:00 PM
I. Patient Details/Personal Data or Information
a. Age: 29
b. Sex: Female
c. Birthdate: 01/05/1993
d. Birthplace: Kapangan
e. Citizenship: Filipino
f. Religion: Catholic
g. Occupation: Housekeeper
h. First day of LMP: 05/14/2022
i. EDC: 01/28/2023
j. AOG: 27-28 Weeks
k. Previous Pregnancy:
i. G1: 2016
ii. G2: 2018
iii. G3: 2021
iv. G4: Present

II. Family Health History

• Hypertension
NCP: PROBLEM 1: Actual
DATA GOALS/ Expected outcomes ACTION/ NURSING RATIONALE RESPONSE &
INTERVENTIONS EVALUATION
Subjective findings: STG: Within 8 hour/s of NI the patient will Provide an open environment and Promotes a free discussion of After 8 hr/s of NI, the patient was
“Tanggap ko na pero andoon be able to function at normal a trusting relationship. feelings and concerns. able to
pa rin iyong sakit, tsaka developmental level and perform function at normal developmental
nahihirapan pa ako magsabi activities of daily living. Help to survive during times of The newly bereaved can be stunned level and performed activities of
ng nararamdaman ko”, as acute grief; ensure that the client and helpless. daily living.
verbalized. As evidenced/manifested by no reports maintains proper nutrition; help
of change in appetite and sleep pattern the client determine a routine to As evidenced/manifested by no
Objective findings: and can be seen continuing daily make it through the day. reports of change in appetite and
• G4P4 fetal death in activities independently. sleep pattern and can be seen
utero 27-28 weeks Use therapeutic communication These skills convey belief in the continuing daily activities
AOG, delivered in skills of active listening, silence, client's ability to deal with situations independently.
cephalic presentation, and acknowledgement. Respect and develop a sense of competence.
stillbirth by NSD LTG: After 24 hrs of NI the patient will be the client's desire or request not Clients may not be ready to discuss STG is FULLY MET.
• Observed crying upon able to express feelings of sadness and to talk. feelings and situations, and
initiation of conversation plan for the future one day at a time. respecting the client's own timeline After 24 hr/s of NI, the patient was
about miscarriage conveys confidence. able to express feelings of sadness
• With 1L D5LRS + 20 U and plan for the future one day at a
As evidenced/manifested by
of oxytocin infusing well Expression of feelings can facilitate time.
verbalization of feelings and Give information that feelings are
on left hand the grieving process, but destructive
concerns and demonstration of initial okay and are to be expressed
• Initial vital signs as integration of loss into daily life. appropriately. behavior can be damaging. As evidenced/manifested by
follows: verbalization of feelings and
o BP: 120/80 mmHg concerns and demonstration of
o T: 36.2C initial integration of loss into daily
o RR: 16 cpm Encourage the client to cry out Grief work is work and is best done
life.
o CR: 86 bpm their grief and to express feelings, as an active process in which the
o SPO2: 95% including sadness or anger. grieving client expresses and feels
the grief. LTG is FULLY MET.

Focus/ Nursing Dx: (PE/S)

Grieving related to loss of Actively listen to the client's grief; These behaviors do not help and can
a child secondary to do not interrupt, do not tell your often hurt.
stillbirth. own story, and do not offer
meaningless platitudes.

Help the client identify previous Coping strategies used previously

personal coping strategies. are helpful in dealing with loss.

Provide information about the This information helps normalize the

grief process, including the grief experience and provides the
stages of grieving; help the client client with hope that she can survive.
realize that the grieving process
takes time and is painful.

PROBLEM 2: Risk
DATA
Subjective findings:
N/A
Objective findings:
• G4P4 fetal death in
utero 27-28 weeks
AOG, delivered in
cephalic presentation,
stillbirth by NSD
• With initial vital signs
as follows:
o BP: 120/80 mmHg
o CR: 86 bpm
o RR: 16 bpm
o T: 36.2C
o SPO2: 95%
Focus/ Nursing Dx: (PE/S)
Risk for complicated
grieving related to loss of a
child secondary to
stillbirth.
GOALS/ Expected outcomes
STG: Within 8 hour/s of NI the patient
will be able to acknowledge awareness
of risks and impact of dysfunctional
situations.
As evidenced/manifested by
verbalization of understanding about
the normal grieving process.
LTG: After 24 hrs of NI the patient will
be able to participate in work and self-
care activities of daily living.
As evidenced/manifested by eating
healthy food, maintaining proper body
hygiene, and getting good quality
sleep.
Identify and promote family and
social support systems.
ACTION/ NURSING
INTERVENTIONS
Assess for causes of dysfunctional
grieving.
Assess client's ability to manage
activities of daily living and period of
time since loss has occurred.
Identify the stage of grief being
expressed.
Identify problems of eating and
sleeping; ensure that basic human
needs are being met.
Identify if client is experiencing
depression or another emotional
disorder; determine if suicidal and
refer to counseling as appropriate.
A supportive environment enhances
the effectiveness of interventions and
promotes a successful grieving
process.
RATIONALE
Life circumstances can interfere with
normal grieving and can be risk
factors for dysfunctional grieving.
Feelings of overwhelming sadness,
exhaustion, and inertia can occur with
active grieving interfering with life
activities; however, when they persist
and interfere with normal activities,
client may need additional
assistance.
Stages of grief may progress in a
predictable manner or stages may be
random or revisited.
Losses often interrupt appetite and
sleep.
Depression and the risk of suicide
can accompany dysfunctional
grieving.
RESPONSE &
EVALUATION
After 8 hr/s of NI, the patient was
able to acknowledge awareness
of risks and impact of
dysfunctional situations.
As evidenced/manifested by
verbalization of understanding
about the normal grieving
process.
STG is FULLY MET.
After 24 hr/s of NI, the patient was
able to participate in work and
self-care activities of daily living.
As evidenced/manifested by
eating healthy food, maintaining
proper body hygiene, and
getting good quality sleep.
LTG is FULLY MET.
Have client identify familial, religious, This may help bring loss into
and cultural factors that have perspective and promote grief
meaning for her. resolution.

Assist family to understand and be Family members inadvertently

tolerant of client's feelings and hamper client's progress through
behavior. grief by expressing their feelings in
anger for client behavior they deem
unacceptable, rather than recognizing
the basis is grief.

Encourage client to make time to talk Once these feelings are shared,
to family members about the loss family members can begin to accept
with the help of professional support the unacceptable
as needed and without criticizing or
belittling each others' feelings about
the loss.

Encourage resuming involvement in Keeping life to a somewhat normal

usual activities, exercise, and routine can provide individuals with
socialization within physical and some sense of control over events
psychological abilities. that are not controllable.

Encourage expression of anger, fear, These feelings are part of the

and anxiety. grieving process; to accomplish the
work of grieving, they need to be
expressed and accepted.

Permit verbalization of anger with This enhances client safety and

acknowledgement of feelings and promotes resolution of the grief
setting limits regarding destructive process.
behavior.

Help client recognize that sadness The sadness associated with chronic
will occur at intervals for the rest of sorrow is permanent, but as the grief
her life but will become bearable. resolves there can be times of
satisfaction and even happiness.