NURSING CARE PLAN (PRIORITY NUMBER 1) Assessment Subjective data: Nagdurugo ang aking sinapupunan as verbalized by the patient.

Objective data: With vaginal bleeding With blood loss of 220ml With decreased RBC (3.18x1012/L) (Feb. 14,2012) Weak in appearance With body malaise Nursing Diagnosis Deficient fluid volume: Hypovolemia related to increased vascularity of the chorionic villi as evidenced by vaginal bleeding, blood loss of 220 ml and decreased RBC count. Planning At the end of the shift, the patient will be able to: Verbalize understanding of causative factors and purpose of individual therapeutic interventions and medication. Demonstrat e behaviors to monitor and correct deficit, as indicated. Intervention Independent: Assess vital signs, noting the blood pressure and pulse rate. Rationale These changes in vital signs are associated with fluid volume loss and/ or hypovolemia. To reduce pressure on fragile skin and tissues. Evaluation Goals met: The patient verbalized understanding of causative factors and purpose of individual therapeutic interventions and medication. The patient also demonstrated behaviors to monitor and correct deficit indicated.

Change the position frequently, turn side to side every 2 hours if necessary. Discuss factors related to occurrence of deficit as individually appropriate.

Early identification of risk factors can decrease occurrence and severity of complications associated with hypovolemia.

 Measure the amount of blood loss.

To note how blood loss affects the patients fluid volume status. To informed the patient for the possible therapeutic effects of the drug. To prevent the recurrence of vaginal bleeding associated with frequent motion/ movements.
To replace

Explain the drug which is ordered to the patient and how it takes its function. Instruct the patient to maintain at bed rest.

Provide Intravenous (IV) fluids as ordered by the physician.

and conserve blood volume contrary to the blood loss caused by vaginal bleeding.