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NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION


Independent:
Subjective: Acute pain related Abruptio placenta After 8 hours of • Monitor amount • To measure After 8 hours of
to collection of nursing of bleeding by the amount of nursing
“Bigla na lang blood between is premature interventions, the interventions, the
weighing all blood loss.
sumakit ng uterine wall and separation of the patient will pads. patient was able to
matindi ang tiyan placenta. normally demonstrate use • Investigate pain • Changes in demonstrate use of
ko , kahit 22 implanted of relaxation skills, reports, noting location or relaxation skills,
linggo palang placenta in the other methods to location, intensity are other methods to
ang promote comfort. duration, not promote comfort.
third trimester.
ipinagbubuntis intensity (0-10 uncommon
ko” (I’m 22 weeks There are two scale), and but may
pregnant and I feel a types of abruption characteristics reflect
sharp pain in my
placentae; (dull, sharp, developing
abdomen) as
concealed constant). complications.
verbalized by the
hemorrhage and • Monitor maternal • Early
patient.
vital signs and recognition of
external
fetal heart rate possible
Objective: hemorrhage. With through adverse
a concealed continuous effects allows
• Abdominal
hemorrhage, the monitoring. for prompt
guarding.
placenta intervention.
• Measure and • Fundal height
• Muscle separation
record fundal may increase
tension. centrally, and a
height. with
large amount of concealed
• Irritability. blood is bleeding.
accumulated • Position mother • To enhance
• V/S taken as in the left lateral placental
follows: under the
placenta. When position, with the perfusion.
head of the bed
T: 37.3 an external
elevated.
P: 95 hemorrhage is • Provide comfort • Promotes
R: 22 present, the measure like relaxation and
Bp: 100/70
separation is back rubs, deep may enhance
along the breathing. patient’s
placental margin, Instruct in coping
relaxation or abilities by
and blood flows visualization refocusing
under the
membranes and exercises. attention.
through cervix. Provide
diversional
Women at risk for activities.
developing
abruption Collaborative:
placentae include • Administer • To supply
those with history oxygen as adequate
indicated. oxygen to the
of hypertension or
fetus and
previous mother and
abruption prevents
placenta, further
abdominal trauma complication.
during pregnancy,
anomaly of the
umbilical cord,
uterine fibroids,
advanced
maternal age,
cigarette
smoking, and
cocaine abuse.