ASSESSMENT NURSING SCIENTIFIC EXPLANATION OBJECTIVES INTERVENTIONS RATIONALE EXPECTED OUTCOME

DIAGNOSIS
Subjective Cues: Grieving Abruptio placenta is a complication of Short term: Independent Short term:
The pt. verbalized “I still can’t related to fetal pregnancy that occurs late in the
believe that my baby is gone. I death as pregnancy. It is defined as the After 6-7 hours of - Assess the patient’s After 6-7 hours of nursing
evidenced by nursing - Emotional reactions interventions, the patient shall
don’t know how I’m supposed to termination of
premature separation of the placenta
interventions, the
understanding of the incident of the patient may have acknowledged impact or
live anymore.” pregnancy from the uterus prior to delivery of the patient will be able to concerning the death of the hinder her ability to effect of the grieving process
fetus. When the placenta detaches, it acknowledge impact fetus. Provide accurate and identified and expressed
process information
The pt. also verbalized “I can’t becomes damaged and it can release or effect of the information and address feelings freely and effectively.
and interpret the
look ahead anymore, all my large amounts of thromboplastin into grieving process and misconceptions centered on
identify and express importance of events.
future seems to have gone and the maternal circulation and can cause the willingness and ability of
feelings freely and the patient to listen
it’s too painful to even try and Disseminated Intravascular
effectively.
think about it as my baby isn’t Coagulation (DIC). This, in turn, causes effectively.
going to be in it.” a major clotting event in the mother’s
- Assess the patient’s - Provides opportunity Long term:
body or the mother may get micro Long term:
depression and its severity. for the patient to
embolisms throughout her body which
Objective Cues: After 2-3 days of acknowledge her After 2-3 days of nursing
can affect profusion to major body
nursing interventions, feelings and promotes interventions, the patient shall
organs that will deplete the mother’s have demonstrated adaptive
The patient may manifest: the patient will be able patient comfort.
clotting factors. Hence, it will cause a to demonstrate grieving behaviors and evidence
- Restlessness
- Weakness serious problem as there is an open adaptive grieving of progression towards grief
- Grieving may be
- Detachment wound from where the placenta behaviors and - Allocate a private room if resolution.
dysfunctional if not completed
- Lack of focus detached off the uterine wall which evidence of the patient wants it, with
that can result to disturbing
- Helplessness predisposes the mother to be at risk for progression towards
behaviors which may affect
- Powerlessness hemorrhage. Since the mother was in grief resolution. patient’s safety, family and
-Disorganization serious condition due to DIC and
-Psychological distress hemorrhagic shock, delivery of the
baby was needed. However, the
dilatation of her uterine cervix remains
at 2 cm which indicates that delivery
could not be expected. Thus, a
hysterectomy was performed to
terminate the life-threatening
pregnancy to prevent maternal
hemorrhage leading to the grieving of
the mother due to fetal loss.
REFERENCE:
Skills, N., Videos, N., School, N., Plans,
N., Quizzes, N., Jobs, N., & Review, N.
(2021). Registered Nurse RN.
Retrieved 23 February 2021, from
https://www.registerednursern.com/
regular contact by healthcare marriage relationship.
providers.
- Observe and recognize
patient’s grief being
displayed (withdrawal,
anger, denial, depression
and etc.) and apply
therapeutic communication
skills when conversing to
the patient. (active listening,
respecting patient’s desire
not to talk,
acknowledgement)
- Discover the extent of the
loss to the patient and
observe the desire for
pregnancy.
- Include the patient's
partner in the planning of
care, which gives the
partner the opportunity to
be seen individually
and reinforces discussion of
concerns.
- Assist the patient in
coming up with effective
coping strategies.
- Provide physical care,
such as bathing, providing
back rubs, and
nourishment as needed,
and allow the patient to
engage at the level of
ability.
Dependent
- Administer anti-anxiety- Provides relief and helps to
- To help manage the patient’s
emotional responses and
establish a trusting
relationship in which she feels
free to express any concerns.
- To determine the magnitude
or weight of the pregnancy loss
as well as its emotional impact
to the patient.
-Including the patient's partner
in the planning and decision-
making process acknowledges
that the partner has also lost a
child and will need time to
convey feelings of loss and
obtain help without having to
support the patient and others.
- Coping strategies provides
the patient with ways to cope
with her grieving.
- Showing care and nurturing
the patient will help to
conserve the energy needed to
meet the demands of the
grieving process. The
participation in self-care
maintains a sense of self-
esteem and competence.
 medications as indicated. reduce grief-related anxiety.

- Administer sleep-inducing
- - Has a calming effect and
medications as per doctor’s helps to initiate, maintain, or
order. prolong sleep.

Interdependent

- - Refer patient for psychiatric-To meet ongoing needs and

therapy, if necessary. facilitate grief work.

- - Refer patient to additional - To provide support and help

resources such as the patient cope with the
counseling, support groups impact of the pregnancy loss.
and psychotherapy.