Cues Objective: >exposure to environment >Improper hygiene >Inappropriate use of antibiotic drugs >Unsafe sexual intercourse

Nursing Diagnosis Risk of infection due to miscarriage or abortion.

Inference The immune system is alerted that an invader has entered the body. Cytokines are the messengers that alert the body to fight the infection. Depending on the type of infection, there are other defender the immune system calls up to join the fight. The result of all this acting often results in a fever. Infection causes blood vessel to enlarge in other to increase the amount of blood containing phagocytes & lymphocyte to the site of infection.

Planning after 4hrs of nursing intervention; >the patient verbalize understanding of individual causative/risk factor >Identify interventions to prevent risk of infection. >Demonstrate techniques; life style changes to promote safe environment.

Nursing Intervention Dependent: >asses for sign and symptoms of sepsis; fever, chills & diaphoresis. >advice patient for proper hygiene. >review individual nutritional needs and appropriate exercise. >promote safer sex. >Provide info. In appropriate community & national education programs. Independent: >Emphasize necessity of taking antivirals/ antibiotics as directed. >discuss of importance of not taking antibiotic using leftover drugs unless specifically instructed by healthcare provider.

Rationale >To monitor if the patient is high risk for infection. >A first line of defense against infections. >to increase the immune system to fight against infection. >to prevent spread of microorganisms. >to increase awareness of & to prevent of communicable disease >premature discontinuation of treatment when current begins to feel well may result in return of infection & potentiate drug resistant strains.

Evaluation After 4hrs of my nursing intervention the patient adopted new information on how to prevent herself for infection.

Cues

Nursing Diagnosis Miscarriage due to lack of knowledge for benefits of taking vitamins and prenatal checks-up.

Inference

Planning

Nursing Intervention

Rationale

Evaluation

Subjective: wala akong ininum na kahit anong vitamins at hindi pa ako nag papa checkup as verbalizes by the patient. Objectives: >body weakness >pallor >viganal bleeding T-36.9 P-85 R-17 BP-80/60

Vaginal bleeding originates from the decidual implantation site or from the placenta. The onset of bleeding may follow or precede fetal demise. Immunologic, hypoxic & vascular lead to final common pathway of severe villous or placental dysfunction resulting in embryonic or fetal demise.

After 4hrs of nursing intervention: >identify interference to learning of specific action to deal w/them. >exhibit increase interest/assume responsibility for own learning beginning to look for info & ask questions. >verbalizes understanding of conditions process & treatment. >initiate necessary lifestyle changes & participate in treatment regimen.

>Explain to the patient why miscarriage happens. >Explain to the patient the importance of taking vitamins and prenatal checkup >asses the level of the clients capabilities & the possibilities of the situation. >discuss to the patient the right birth spacing. >Explain to the patient the effect of smoking to her baby.

>to know the patient why she experience miscarriage. >to know the patient the benefits of vitamins & prenatal checks-up for her and for her baby. >the patient may need help & for nurse (me) to learn about the situation. >to know the benefits of birth spacing and how to apply it to her life. >for avoidance using cigarette s when/during pregnancy.

After my 4hrs of nursing intervention: The patient adopted a lot of information about her situation. The patient responses to learning plan & action performs.

Cues

Nuring Diagnosis Deficient fluid volume related to excessive blood loss.

Inference

Planning

Nursing Intervention

Rationale

Evaluation

Objectives: >delayed capillary refill >restlessness T-36.9 P-85 R-17 BP-80/60 Subjective: dalawang araw na kong dinugo at masakit ang puson ko as verbalized by the patient.

Threatened abortion occurring before th the 20 week of gestation characterized by cramping & vaginal bleeding w/ no cervical dilation, it may subside or an incomplete abortion may follow.

After 4hrs of my nursing intervention the patient will: >demonstrat e improved fluid balance as evidenced by stable vital sign, good skin turgor and prompt capillary refill.

Independent: >Monitor v/s and compare it to previous normal findings. >note patient s individual physiological response to bleeding such as changes in mentation, weakness, restlessness and pallor. >measure central venous pressure, if available. >monitor intake & output & correlate w/ weight changes >maintain bed rest. Dependent: >administer fluids as indicated >administer Vit k >monitor Hb,Hct and RBC

>changes in blood pressure may use for estimate of blood >symptomatology may be useful in gauging severity of length of bleeding episode, worsening of symptoms may reflect continued bleeding or inadequate fluid replacement. >provides guidelines for fluid replacements. >activity increase intra-abdominal pressure & can predispose to further bleeding. >fluid replacement w/isotonic solution depends on the degree & duration of bleeding >promotes hepatic synthesis of coagulation factor to support clotting. >aids in establishing blood replacements needs & monitoring the effectiveness of theraphy.

After 4hrs of nursing intervention the patient was able to demonstrate improved fluid balance as evidenced by stable v/s, good skin turgor and prompt capillary refill.