ASSESSMENT NURSING PLANNING, INTERVENTION RATIONALE EVALUATION

DIAGNOSIS CLIENT GOAL,

Subjective data: Risk for bleeding Short term goal: Independent: Independent: Short term goal:
“Recently related to After 5 hours of 1. Assess the 1. A review of the After 5 hours of
underwent prenatal bleeding receiving nursing client’s menstrual history and receiving nursing intervention,
transvaginal as evidenced by intervention, the client reproductiv prior ultrasonography the client can:
ultrasound. May subchorionic will be able to: e history. if applicable can help
nakita na maliit establish gestational 1. Identify the rules of
hemorrhage and
na subchorionic 1. Identify the rules dating and determine behavior to prevent
uterine atony
hemorrhage o of behavior to whether the pregnancy bleeding during the first
risk for bleeding prevent bleeding location is known trimester of pregnancy.
siya na need during the first (Hendricks et al.,
magamot trimester of 2019). Long Term Goal:
immediately.” as pregnancy. 2. Assess 2. Assess the client’s
After 2 months of
verbalized by the maternal pulse, respiration, and
Long Term Goal: nursing intervention
patient. vital signs. blood pressure every
the client can state relief from
15 minutes and apply a
After 2 months of bleeding as evidence by:
pulse oximeter and
Objective data: nursing intervention automatic blood
the client will state 1. Exhibit self-precaution to
“The Patient pressure cuff, as
relief from bleeding as avoid the recurrence of
taking medicine necessary. This
evidence by: bleeding.
(Duphaston) 2x a provides baseline data
1. Exhibit self- 2. Display normal vital signs
day, every 12 on maternal response
precaution to and stable fetal heart rates.
hours to prevent to blood loss. With
avoid the 3. Identify individual risks and
significant blood loss,
miscarriage and recurrence of engage in appropriate
the pulse rate and
regulate the bleeding. behaviors or lifestyle
respiratory rate will
uterine lining” 2. Display changes to prevent or reduce
start to increase as the
normal vital the frequency of bleeding.
heart attempts to
signs and compensate for the
 Weight stable fetal
 (before heart rates. decreased circulatory
pregnancy): 3. Identify volume and the
58 kg individual respiratory system
 Weight risks and increases gas exchange
(during engage in to better oxygenate the
pregnancy): appropriate RBCs. (Martin, P.,
55 kg behaviors or 2022)
lifestyle 3. Instruct 3. Simple fever is
V/S taken as changes to client to significant enough not
follows: prevent or report signs to pay attention to.
reduce the and
 T: 36.7  frequency of symptoms
 BP: bleeding. of infection
95/60 immediatel
mmHg y.
 RR: 20 4. Schedule 4. The client may avoid
bpm the client’s strenuous activities for
periods of 24 to 48 hours to
 PR: 99
rest and prevent a threatened
bpm activities. abortion, assuming the
threatened miscarriage
involves a live fetus
and presumed
placental bleeding.
Complete bed rest is
usually not necessary
as this may appear to
stop the vaginal
bleeding but only
because blood pools
vaginally. When the
client does ambulate
again, the vaginal
blood collection will
 drain, and bleeding
will reappear. (Martin,
P., 2022)
5. The initial response of
5. Auscultate a fetus to decreased
and report oxygenation is
FHR; note tachycardia and
bradycardia increased movements.
or A further deficit will
tachycardia result in bradycardia
. Note and decreased activity.
change in In placenta previa, the
hypoactivit fetus or neonate may
y or have anemia or
hyperactivit hypovolemic shock
y. because some of the
blood loss may be fetal
blood. Fetal hypoxia
may occur if a large
disruption of the
placental surface
reduces the transfer of
oxygen and nutrients.

Collaborative:
Collaborative: 1. Electronically
1. Carry evaluating the FHR
out/repeat response to fetal
NST, as movements is useful in
indicated. determining fetal well-
being (reactive test)
versus hypoxia
(nonreactive).
Additionally, this
 assesses whether labor
and fetal status are still
present. An external
system avoids
additional cervical
trauma. (Martin, P.,
2022)
2. Ultrasound is used to
2. Assist with determine if the fetus
ultrasonogr is living and supplies
aphy and information about
amniocente placental and fetal
sis. Explain well-being. Using an
procedures. amniocentesis
technique, an analysis
of the
lecithin/sphingomyelin
(L/S) ratio in
surfactant is a primary
test of fetal maturity.
(Martin, P., 2022)