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nursing care plan abortion

Updated on November 19, 2009

Cues

· Active fluid volume loss as seen in pad saturation, active vaginal bleeding

· Vital signs like increased RR, initially increased HR/PR and BP which eventually goes down if no compensatory mechanism

· Skin pallor

· Decreased urine output

· Slow capillary refill

· Change in mental state-confused/disoriented

· Dry oral mucous membranes

Nursing Diagnosis

Fluid volume, deficient related to active fluid volume loss secondary to hemorrhage

Goals/Objectives

Within 24 hours:

The patient will be able to maintain fluid volume at a functional level.

Plans/Interventions

1. Assess causative factors ( test for pregnancy), retained fetal/placental parts.

2. Estimate fluid losses.

3. Assess vital signs.

4. Assess for physical signs of shock.

5. Assess/review laboratory data.

6. Correct/replace losses.

a. Assist in D&C in cases of inevitable , complete,incomplete,missed miscarriage

b. Limit activity for those with threatened abortion

c. Administer IV fluids and blood products/plasma expanders a s ordered

7. Monitor vital signs.

8. Maintain accurate I & O especially monitoring pad saturation

Evaluation

Within 24-48 hours patient will manifest:

1. Stable vital signs

2. Adequate urinary output with normal S.G.

3. Moist mucous membranes, good skin turgor, good skin color and fast capillary refill

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