ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Acute Pain r/t SHORT TERM Independent Encourage expression of SHORT TERM
“Masakit ang cervical dilation as After 4 hours of Educate the client about concerns. After 4 hours of
kaliwang siko at evidenced by nursing the condition and Information, and knowing nursing
puson ko nung vaginal spotting, interventions, the treatment. what to expect can help interventions, the
thursday pa” verbalizations of patient will report lower the anxiety level patient reported
5/10 pain score pain pain relieved which can enhance the relief and free from
perception of pain. pain
Objective: LONG TERM Using precautionary LONG TERM
Instruct patient about
T: 36.9 After 2 days of measures prevents tissue After 2 days of
appropriate risk-
BP: 120/80 nursing intervention, trauma and reduces the nursing
HR: 75 patient will reduction interventions risk of further bleeding and intervention,
RR: 19 demonstrate infection. patient
O2SAT: 98% reduced/controlled Early identification and demonstrated
LMP: 02/11/23 bleeding Educate the patient and treatment of bleeding can reduced/controlled
Vaginal spotting family about signs and reduce blood loss bleeding
Positive amount of bleeding that complications
Pregnancy Test need to be reported to a
G1T0P0A0L0 healthcare provider

DEPENDENT Analgesic will be used to

relieve pain
Administer analgesic as
prescribed
To replace blood loss and
reduce further bleeding
Administer reversal
agents or blood products
that are safe for
pregnant woman as
ordered
 ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Knowledge Deficit SHORT TERM Independent Establishing rapport help SHORT TERM
“Masakit ang r/t lack exposure After 2 hours of Establish rapport to the the patient to After 2 hours of
kaliwang siko at of information as nursing client communicate and trust the nursing
puson ko nung evidenced by interventions, the health provider interventions, the
thursday pa” unfamiliarity to patient will patient participated
5/10 pain score the situation due participate in Determine patient’s Patient may not be in learning process
learning process readiness and barriers to physically, mentally,
to first pregnancy
Objective: emotionally capable now Patient verbalized
learning
T: 36.9 simple terms and
Patient will verbalize
BP: 120/80 To identify the effect of the implications of the
HR: 75 simple terms and Identify patient’s patient’s habits to clinical situation
RR: 19 implications of the lifestyle pregnancy LONG TERM
O2SAT: 98% situation After 2 days of
LMP: 02/11/23 To reduce/ avoid possible nursing
Vaginal spotting LONG TERM Health teaching complications of her intervention,
Positive After 2 days of regarding pregnancy and pregnancy patient
Pregnancy Test nursing its risks during first demonstrated
G1T0P0A0L0 interventions, the trimester understanding of
patient will the condition and
demonstrate of COLLABORATIVE To monitor the patient’s initiated necessary
understanding of the pregnancy lifestyle changes
Refer to OB GYN
condition and will
initiate necessary
lifestyle changes

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

 DIAGNOSIS INTERVENTION
Subjective: Risk for Ineffective SHORT TERM Independent Defining characteristics will SHORT TERM
“Masakit ang Tissue Perfusion After 4 hours of Assess for signs of provide baseline for future After 4 hours of
kaliwang siko at related to nursing decreased tissue comparison nursing
puson ko nung bleeding and interventions, the perfusion interventions, the
thursday pa” diminished blood patient will Measure capillary refill To determine adequacy of patient
5/10 pain score flow demonstrate systemic circulation demonstrated
adequate perfusion Monitor vital signs This is necessary for adequate tissue
Objective: LONG TERM baseline data to determine perfusion as
T: 36.9 After 2 days of signs and symptoms of evidenced by stable
BP: 120/80 nursing intervention, hypovolemic shock vital signs, good
HR: 75 patient will capillary refills at 2-
RR: 19 demonstrate 3 seconds and
O2SAT: 98% behaviors to DEPENDENT To supply for possible fluid adequate urine
LMP: 02/11/23 maintain adequate Administer intravenous volume deficit and blood output
Vaginal spotting circulation fluids and blood loss
Positive products as indicated LONG TERM
Pregnancy Test The use of vasopressors After 2 days of
G1T0P0A0L0 Administer vasopressors must be done with great nursing
as prescribed caution in hypovolemic intervention,
shock. The vasopressors patient
may lead to higher blood demonstrate
pressure but at the behaviors to
expense of diminished maintain adequate
organ perfusion. circulation

DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING

ACTION RESPONSIBILITIES
Generic Name: Used for threatened For treatment of Vaginal bleeding, Vomiting Assess if patient is
Dydrogesterone abortion. It restores progesterone where the cause has Dizziness allergic to
the luteal function, deficiency such as not been established Disturbed liver dydrogesterone
Brand Name: thereby decreasing threatened abortion, Presence of serious function Assess patient history
Duphaston the incidence of first habitual abortion, liver disorders, or Cramps of tumors and
trimester abortions. regulation of the serious liver Weight gain meningioma.
Classification: It also relaxes the cycle. disorders in medical Not given if patient’s
Progesterone, smooth musculature history until the liver bleeding is not
Progestin of the uterus and function values have determined and
modulates maternal returned to normal. identified.
Dosage: 10mg immune response. It May be taken with or
functions by means without food.
Route: Oral of correcting the
progesterone levels,
leading to the
stimulation of the
uterine walls. This
enhances the
preparation for
pregnancy as well as
protecting an existing
pregnancy.