Originally Posted by cutegurl
anyone there who could help me to make a care plans about threatened abortion and vaginal bleeding. i dont have any references. i really need help because tommorw is my deadline to submit it..
The steps of a care plan are as follows:
THE STEPS OF THE NURSING PROCESS (WRITTEN CARE PLAN)
Assessment (collect data)
Nursing Diagnosis (group your assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)
For the Assessment of a patient with vaginal bleeding and threatened abortion you would look for the following signs and symptoms:
a history of:
pelvic inflammatory disease
gonorrhea
muliparity
maternal age over 35
previous cesarean sections
previous history of abortions, D&Cs, cervical conization
infertility and use of reproductive techniques or medications
multiple gestation (twins, triplets, etc.)
hypertension or hypotension
pallor, cold, clammy, skin
faintness
syncope
dizziness
anxiety, apprehension, fear
nausea and/or vomiting
abdominal pain, colicky abdominal pain, one-sided abdominal pain (as in a tubal rupture)
time of conception (4-5 weeks after conception may indicate the possibility of an ectopic pregnancy)
tachycardia
delayed capillary refill
hypothermia
abnormal labs
urine is positive for protein
elevated WBC
low hemoglobin and hematocrit levels
sudden decline in estrogen and progesterone levels (with spontaneous abortion)
low HCG titer (in ectopic pregnancies)
Your Nursing Diagnosis is determined by the presence of any of the above abnormal signs or symptoms (and any others you might have found during your assessment). However, some ideas for nursing diagnoses would include:
Deficient Fluid Volume
Ineffective Tissue Perfusion, Uteroplacental
Fear
Acute Pain
Knowledge Deficit, learning need
Risk for Maternal Injury
In the Planning step you develop your nursing interventions and goals for the patient. Your interventions are always directed toward the symptoms the patient is having as determined from your assessment. In general, your goals will reflect what your nursing interventions are and will be centered around:
maintaining the patient's circulating volume of fluid
assisting with the efforts to sustain the pregnancy if it is possible
to prevent complications
to provide emotional support to the patient/couple
provide information about short and long term implications of the hemorrhage
Those first three steps are the major part of the care plan. The last two are based upon how the care plan works and your evaluation of it and reformulation of interventions and goals. Steps 4 and 5 are ongoing.
You should be able to find references for all the above in an OB textbook and/or by looking up the following conditions in a textbook or on the Internet: spontaneous abortion, ectopic pregnancy, hydatidiform mole (gestational trophoblastic disease), placenta previa and abruptio placentae.
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Re: CAREPLANS HELP PLEASE! (with the R\T and AEB)
