Spontaneous - ,,terminated(:PerinatalLoss (:PrenatalHemorrhage Circulat

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Spontaneous Termination This plan of care applies to the client whose pregnancy is being, or has been involuntarily, terminated.  (To be used in conjunction with CP: Perinatal Loss.) CLIENT ASSESSMENT DATA BASE (Refer to “Client Assessment Data Base” section in CP: Prenatal Hemorrhage.) Circulation History of essential hypertension, vascular disease, ABO incompatibility Ego Integrity Pregnancy may/may not have been planned. May be very anxious/fearful. Elimination Chronic nephritis Food/Fluid Poor maternal nutritional status Pain/Discomfort Pelvic cramping, backache Safety Exposure to toxic/teratogenic agents History of pelvic inflammatory disease, STDs, or exposure to contagious diseases such as rubella, CMV, or active  herpes Sexuality Vaginal bleeding, ranging from dark spotting to frank bleeding. Examination may reveal premature dilation of cervix, bicornate or septate uterus, uterine fibroid tumors (leiomyoma),  or other abnormalities of the maternal reproductive organs. Note EDB (80% of spontaneous abortions occur in first trimester). Teaching/Learning Family history of genetic conditions DIAGNOSTIC STUDIES (Refer to CP: Prenatal Hemorrhage.) NURSING PRIORITIES 1. Evaluate client status. 2. Prevent complications. 3. Support the grief process. 4. Provide appropriate instruction/information. DISCHARGE GOALS 1. Free of complications following procedure
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2. Support resources identified/contacted 3. Specific therapeutic needs and concerns understood NURSING DIAGNOSIS: Injury, risk for maternal Risk Factors May Include: Abnormal blood profile (decreased hemoglobin, altered clotting  factors) Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an  actual  diagnosis] DESIRED OUTCOMES/EVALUATION  Report any bleeding. CRITERIA—CLIENT WILL: Be free of negative side effects from termination. ACTIONS/INTERVENTIONS RATIONALE Independent Assess vital signs and urine output. Note skin  Early recognition of developing problems is  color/temperature. Estimate blood loss; conduct  important for prompt treatment. pad count/weight. Assess for and review signs/symptoms of DIC:  Fetal autolysis of the products of conception,  abnormal clotting factors, elevated fibrin  which release thromboplastin, can cause DIC. degradation products levels.
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This note was uploaded on 02/01/2011 for the course PNR 182 taught by Professor Toole during the Spring '10 term at Orangeburg-Calhoun Technical College.

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Spontaneous - ,,terminated(:PerinatalLoss (:PrenatalHemorrhage Circulat

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