Name: Gillan Godwin Donel L.
Eugenio
Year Level/Section: BSN 2-2 (Group 3)
ASSESSMENT
SUBJECTIVE:
The patient stated that she
had a vaginal bleeding that
started 2 days PTA.
The patient verbalizes that
she had a mild dull lower
abdominal pain.
OBJECTIVE:
Laboratory tests:
Haemoglobin 11.1g/dl
White Cell count 3.9 x
10^9/L
Platelets 201 x 10^9/L
Anticardiolipin antibody:
Positive
Lupus anticoagulant:
Positive
Physical Examination:
The abdomen is non-
distended but tender
suprapubically. The
cervical os is open and
NURSING CARE PLAN
NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
 Risk for imbalance After 6 hours of proper INDEPENDENT: After 6 hours of proper
Fluid Volume nursing intervention the  Monitor vital signs. -To know the changes in nursing intervention the
related to vaginal client will demonstrate PR and RR since it can client will demonstrate
bleeding AEB improved fluid balanced. increase when improved fluid balanced
opened cervical os. experiencing a fluid deficit. AEB:
- Client has an
 Note patient’s - Symptomatology may be improved fluid
individual useless in gauging severity volume.
psychological or length of bleeding - Client has no
response to episode. vaginal bleeding
bledding such a - Client has no
sweakness, abdominal pain or
restlessness and cramping.
pallor. -
-Promotes relaxation GOAL MET
 Promote
calm/restful
environment.
-Provide guidelines for
 Monitor intake and fluid replacement.
output.
DEPENDENT: -To improve the likelihood
 Oral low-dose of of a successful live birth.
aspirin and low-
molecular-weight
products of conception are subcutaneous
removed from the os. heparin from the
time of positive
pregnancy test
should be given in
subsequent
pregnancies.
- To promote fluid
COLLABORATIVE: management.
 Administer IV
fluids as prescribed
using infusion
pumps.
Name: Gillan Godwin Donel L. Eugenio
Year Level/Section: BSN 2-2 (Group 3)
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE: Risk for infection related to After 1 hour of nursing INDEPENDENT: After 1 hour of
The patient stated “2 days related to tender, hot and intervention the patient Monitor temperature every Increased local temperature nursing intervention the
na po akong may fever at boggy uterus as evidence should be able to determine 4 hours; notify physician if is a classic sign of wound patient was able to
di maganda ang by elevated body the prevention and methods temperature is greater than infection. determine the prevention
pakiramdam ko” temperature. of transmission of 100.8 F or 38.2 C. and methods of
infection. transmission of infection.
Patient stated a 4/10 sharp, Make health teachings
intermittent, localized and especially in identification To help the client GOAL MET
aggravated by movements. of environmental risk modify/change/avoid some
factors that could add up of the environmental
OBJECTIVE: on infection. factors present which could
Abdominal pain reduce the incidence of
Smelly watery discharge DEPENDENT: infection.
Hot uterus Administer
Very tender uterus antibiotics as ordered by
Uterus feels boggy the physician Antibiotics will help kill
Vaginal bleeding and stop the proliferation
and growth of the bacteria
which could cause
VITAL SIGNS AS COLLABORATIVE: infection.
FOLLOWS: Contact laboratory
BP: 110 department to evaluate all
PR: 96/min abnormal laboratory
Temp: 38.1 c findings, especially culture/
sensitivities and complete
blood count (CBC).
Gillan Godwin Donel L. Eugenio
BSN 2-2

PATIENT EDUCATION FORM

Name of patient: N/A Gender: Female Diagnosis: Antiphospholipid syndrome
Age: 34 years old Date admitted: N/A

Main Concept or Topic: Management for patients with antiphospholipid syndrome.

Details of patient education content:
When compared to pregnant women without antiphospholipid syndrome (APS), pregnant women with APS have a higher chance of developing a thrombosis (blood clot in a vein or artery) and
miscarriage. They may also be at risk for additional pregnancy-related issues, including as hypertension and reduced blood supply to the fetus, which can lead to intrauterine growth restriction.
Several treatments are available to reduce these risks.
The following is a general description of available treatments and what to avoid.

 Take aspirin – In combination with heparin injections, low-dose aspirin may be used to treat pregnant women with APS. 
 Take heparin - Heparin must be administered via an injection, either beneath the skin or into a vein.
 Unfractionated heparin must be injected twice daily and is associated with an increased risk of severe bleeding, a low platelet count, and osteoporosis.
 In comparison to unfractionated heparin, LMWH should be injected once a day and has a lower risk of severe bleeding, low platelet count, and bone weakening (osteoporosis).
 Psychological support should be given with regular reassurance ultrasound scans in the first trimester. There is evidence that shows repeated ultrasound scans for reassurance alone
improve the outcome after recurrent miscarriage.
 Warfarin administration – Because of the potential dangers to the developing fetus, warfarin is not normally suggested for pregnant women with APS. Before six weeks of pregnancy,
warfarin must be stopped.
 Women with APS should not use birth control methods that contain estrogen because estrogen can increase the risk of developing a blood clot.
 When taking blood-thinning medications, take extra care to keep from injuring yourself and to avoid bleeding.
 Avoid contact sports or other activities that could cause bruising or injury or cause you to fall.
 Use a soft toothbrush and waxed floss.
 Shave with an electric razor.
 Take extra care when using knives, scissors and other sharp tools.
Gillan Godwin Donel L. Eugenio
BSN 2-2

PATIENT EDUCATION FORM

Name of patient: N/A Gender: Female Diagnosis: Septic Miscarriage
Age: N/A Date admitted: N/A

Main Concept or Topic: Management for patients with Septic Miscarriage.

Details of patient education content:
Further investigations necessary are blood cultures; liver function tests; coagulation screen, group and save; high vaginal and endocervical swabs.
The following is a general description of available treatments and what to avoid.

 Aggressive intravenous fluids should be given as she has intravascular depletion due to sepsis (vasodilatation) and vomiting.

 Evacuation of retained products of conception should be arranged urgently, once the first dose of antibiotics has been given.

 Avoiding sexual contact after a miscarriage lowers the chance of infection.

 Also, after miscarriage to prevent infection use sanitary pads rather than tampons. Wait until your next period before using tampons again.

 Take showers instead of baths.

 Do not douche.

 Do not go into swimming pools or hot tubs.

 Eat healthy foods especially vegetables and fruits that is reach fiber and proteins.

 Take empiric antibiotic- this will help the patient to reduce the patient body pain.

 Also, amoxicillin intake was a highly effective in the treatment of the serious infections associated with septic miscarriage