PATIENT S NAME: A.B.

C AGE: 24 CASE: Spontaneous Abortion ASSESSMENT DIAGNOSIS Subjective: Dinudugo ako, humihilab ang tiyan ko kagabi pa, 12 linggo na ang pinagbubuntis kol as verbalized by the patient. Objective:  Dry mouth  Pale skin  Cool, clammy hands and feet  Diaphoretic  Delayed capillary refill, less than 2 sec  restless  Vital signs taken as follows: BP: 90/60 PR: 95 RR: 27 T: 36 C Fluid Volume deficit related to excessive blood loss.

NURSING CARE PLAN

PLANNING After 8 hours of nursing intervention the patient will demonstrate Obtained baseline vital improved fluid balance signs and continue as evidenced by stable frequent monitoring of BP. vital signs, prompt capillary refill and warm and dry skin. IMPLEMENTATION INTERVENTION RATIONALE INDEPENDENT:

June 21, 2011 EVALUATION

After 8 hours of nursing intervention For early recognition of the patient was able possible adverse to demonstrate effects and allows for improved fluid prompt intervention. balance as evidenced Changes in blood by stable vital signs, pressure may be used prompt capillary refill for rough estimate of and warm and dry blood loss. skin. Symptomatology may be useful in gauging severity or length of bleeding episode. Worsening of symptoms may reflect continued bleeding or inadequate fluid replacement Provide guidelines for fluid replacement

Noted patient s individual physiological response to bleeding such as weakness, restlessness and pallor

Monitored intake and output and correlated it with weight changes Instructed patient to maintain bed rest and schedule activities to provide undisturbed rest periods

Activity increases intraabdominal pressure and can predispose to further bleeding

PATIENT S NAME: A.B.C AGE: 24 CASE: Spontaneous Abortion

NURSING CARE PLAN

DEPENDENT: Administered fluids as indicated Fluid replacement with isotonic solutions depends on the degree and duration of bleeding Promotes hepatic synthesis of coagulation factors to support clotting Aids in establishing blood replacement needs and monitoring the effectiveness of therapy

June 21, 2011

Administered vitamin K as ordered.

Monitored Hb, Hct, RBC count