CASE

Wilma gave birth to twin girls at 38 weeks of gestation 3 years ago. She had spontaneous abortion last year at 12 weeks and
thinks she may be pregnant now because she has missed a menstrual period and is experiencing nausea in the mornings. Wilma’s
LMP began on November 18, 2022.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Objective Data Short Term: Independent: Goal met:

Knowledge deficit
Conduct health Short Term:
GTPAL: G2 T1 P1 A1 L2 regarding condition of Within 4-6 hours of
teaching regarding the After 4-6 hours of nursing
Spontaneous possible pregnancy as nursing intervention,
proper care and course intervention, the client was
abortion (12 the client will:
evidenced by missed of action during able to:
weeks)
menstrual period and pregnancy to prevent Confirm her condition in
LMP: November 1. The client will be able
nausea in the miscarriage. regards with the signs
18, 2022
to confirm her Initiate necessary and symptoms she’s
Vital Signs: mornings as stated by
condition; whether she’s lifestyle changes that experiencing which led
Bp: 90/60 the client.
pregnant or not. will be beneficial to a positive pregnancy
Temp: 36.7 °C result.
RR: 16 bpm throughout the
2. The client will be able Long Term:
PR: 98 bpm pregnancy process.
After 1 week of nursing
Wt: 52 kg to determine whether Assess the client’s OB
intervention, the client was
Ht: 5’4 ft her nausea in the Gyn history.
able to:
BMI: 19.7 mornings are possible Establish a therapeutic
Demonstrate proficiency
symptoms of relationship, conveying
in prenatal care as
Subjective Data pregnancy or is caused empathy and
evidenced by the
Nausea in the by other underlying unconditional positive
healthy pregnancy
morning regard
conditions. process and maintaining
Missed menstrual a healthy lifestyle.
period
CASE
Wilma gave birth to twin girls at 38 weeks of gestation 3 years ago. She had spontaneous abortion last year at 12 weeks and
thinks she may be pregnant now because she has missed a menstrual period and is experiencing nausea in the mornings. Wilma’s
LMP began on November 18, 2022

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Long Term: (when talking or asking

After 1 week of nursing about history of previous
intervention, the client spontaneous abortion.
Instruct ways on how
will
to overcome nausea
and morning
3. The client will be
sickness.
able to overcome Engage the client in
nausea on her daily the learning process
basis. through group
participation and
4. The client will be discussions.
able to demonstrate
mastery of prenatal Dependent:
Conduct pregnancy
care and maintaining
tests and other
a healthy lifestyle.
laboratory tests such as
blood tests and urine
tests.
CASE
Wilma gave birth to twin girls at 38 weeks of gestation 3 years ago. She had spontaneous abortion last year at 12 weeks and
thinks she may be pregnant now because she has missed a menstrual period and is experiencing nausea in the mornings. Wilma’s
LMP began on November 18, 2022

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Collaborative:
Refer the client to
another level of
healthcare specialist,
specifically to
psychologist to
properly assess
whether the client’s
previous case of
abortion had caused
any underlying
condition such as
stress, depression, or
anxiety.