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Assessment Nursing Diagnosis Rationale Expected Outcome Nursing Interventions Rationale Evaluation

1) The patient experienced morning sickness, loss of appetite, and painless bright red vaginal bleeding associated with uterine contractions during her first trimester of pregnancy. 2) The nursing diagnosis is deficient fluid volume due to disrupted placental implantation, which can lead to hypovolemic shock and threaten maternal and fetal health if not addressed. 3) Short term interventions include assessing intake/output hourly, instructing the patient to rest, and monitoring for further bleeding. Long term goals are for the patient to understand the cause of bleeding and engage in appropriate self-care after one week of nursing support.

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Mark Fernandez
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348 views1 page

Assessment Nursing Diagnosis Rationale Expected Outcome Nursing Interventions Rationale Evaluation

1) The patient experienced morning sickness, loss of appetite, and painless bright red vaginal bleeding associated with uterine contractions during her first trimester of pregnancy. 2) The nursing diagnosis is deficient fluid volume due to disrupted placental implantation, which can lead to hypovolemic shock and threaten maternal and fetal health if not addressed. 3) Short term interventions include assessing intake/output hourly, instructing the patient to rest, and monitoring for further bleeding. Long term goals are for the patient to understand the cause of bleeding and engage in appropriate self-care after one week of nursing support.

Uploaded by

Mark Fernandez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Assessment Nursing diagnosis Rationale Expected outcome Nursing Interventions Rationale Evaluation

Subjective: Deficient Fluid Volume Active blood loss or Long term: Assess maternal To obtain baseline date After 1 week of
Patients states that Blood Loss to Disrupted hemorrhage due to After 1 week of vital signs on maternal blood loss nursing intervention
during her first Placental Implantation disrupted placental nursing intervention the patient will be able
semester she suffered implantation during the patient will Establish Rapport To gain patient’s trust to verbalize the cause
pregnancy may manifest
from morning sickness verbalize the cause of of bleeding and
signs and symptoms of Assess color, odor, Provides information
and loss of appetite. bleeding and appropriate
fluid vol. deficient that consistency and amount about active bleeding
She also complaints of may later lead to appropriate of vaginal bleeding versus old blood, tissue intervention.
painless bright red hypovolemic shock and intervention. loss and degree of blood
vaginal bleeding cause maternal and fetal loss
associated with death Short term: After 8 hours of
uterine contraction After 8 hours of Assess hourly intake and Provides information nursing intervention
nursing intervention output about maternal and fetal patient will remain in
patient instructed to physiologic rest position and
Objective: rest, report any compensation to blood report any bleeding.
BP is 110/70 spotting or bleeding loss
PR 115 that indicates
Maintain positive Provide support for the
RR 12 pregnancy
attitude toward about mother to anticipate
Temperature 36.0 complication fetal outcome what might be outcome.

Lab results are Total


placenta previa

Mark Angelo Fernandez

Assessment Nursing diagnosis Rationale Expected outcome Nursing Interventions Rationale Evaluation Subjective: Patients state

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