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ABORTION Nursing Diagnoses and Related Interventions Nursing Diagnosis: Risk for deficient fluid volume related to bleeding

g during pregnancy Outcome Evaluation: Clients blood pressure is maintained at above 100/60 mm Hg; pulse rate is below 100 beats per minute (bpm); only minimal bleeding is apparent; fetal heart rate is maintained at 120 to 160 bpm, with adequate short-term and long-term variability; urine output is greater than 30 mL/hr. Intervention Rationale Alert health care team of emergency situation. Provides maximum coordination of care Place woman flat in bed on her side. Maintains optimal placental and renal function Begin intravenous fluid such as lactated Ringers Replaces intravascular fluid volume; intravenous line is with a 16- or 18-gauge angiocath. established if blood replacement will be needed Administer oxygen as necessary at 610 L/min by Provides adequate fetal oxygenation despite lowered maternal face mask. circulating blood volume Monitor uterine contractions and fetal heart rate Assesses whether labor is present and fetal status; external by external monitor. system avoids cervical trauma Omit vaginal examination. Prevents tearing of placenta if placenta previa is cause of bleeding Withhold oral fluid. Anticipates need for emergency surgery Order type and cross-match of 2 units whole Allows for restoring circulating maternal blood volume if needed blood. Measure intake and output. Enables assessment of renal function (will decrease to under 30 mL/hour with massive circulating volume loss) Assess vital signs (pulse, respirations, and blood Provides baseline data on maternal response to blood loss

pressure every 15 min; apply pulse oximeter and automatic blood pressure cuff as necessary). Assist with placement of central venous pressure Provides more accurate data on maternal hemodynamic state or pulmonary artery catheter and blood determinations. Measure maternal blood loss by weighing perineal Provides objective evidence of amount of bleeding. Saturating a pads; save any tissue passed. sanitary pad in less than 1 hour is heavy blood loss; tissue may be abnormal trophoblast tissue. Set aside 5 mL of blood drawn intravenously in a Tests for possible blood coagulation problem (disseminated clean test tube; observe in 5 min for clot intravascular coagulation; suspect this if no clot forms within formation. time limit) Assist with ultrasound examination. Supplies information on placental and fetal well-being Maintain a positive attitude about fetal outcome. Supports motherchild bonding Support womans self-esteem; provide emotional Assists problem solving, which is lessened by poor self-esteem. ECTOPIC PREGNANCY Nursing Diagnoses and Related Interventions Nursing Diagnosis: Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy Outcome Evaluation: Client states she feels sad at pregnancy loss but is able to deal with situation; has returned to previous level of activities and has forwardthinking plans. A woman who has had an ectopic pregnancy not only has grief stages to work through (she has lost a child) but also may have problems of diminished selfimage and a sense of powerlessness to resolve if

surgery included removal of a fallopian tube. She may believe that she is now half a woman if she equated reproductive structures and childbearing with being feminine. Encourage her to verbalize her concerns about this and future childbearing. The process of working through grief and role images takes weeks to months. It should begin in the hospital, however, where a woman has professional people to help her through the first days and to determine whether she will need further counseling. Nursing Diagnoses and Related Interventions Because the diagnosis of placenta previa with bleeding is an emergency, all goals should reflect the short timeframe of the emergency condition. Nursing Diagnosis: Fear related to outcome of pregnancy after episode of placenta previa bleeding Outcome Evaluation: Client discusses concerns with nurse and other health care providers; states hearing fetal heartbeat helps to reassure her about babys health. Often it is difficult for a woman who has experienced bleeding late in a pregnancy to wait for the baby to come to term, wondering whether her infant will be all right. Regardless of her outward appearance, most likely she is experiencing severe emotional stress. She cannot help but wonder if the next bleeding she experiences will kill her, the infant, or both. She may become so worried about the safety of her child that she begins to think of her baby as already dead. If this happens, she might begin to neglect her diet or her supplementary vitamins because it doesnt matter any more. Listening to fetal heart sounds and being reassured that they are in a healthy range is helpful. She also needs to be able to talk to someone about her fears so she does not feel alone with her concerns.

PRETERM SITUATION Beverly Muzuki is a 20-year-old primipara, 30 weeks pregnant, whom you see in a prenatal clinic. She has had symptoms of a urinary tract infection for the past few days but did not call the clinic because she knew she had an appointment today and thought getting some help for it could wait until she came in. Yesterday she noticed some mild abdominal pain but thought it was irritation from the bladder infection. During the night, she woke twice because of a nagging backache. This morning, she has intermittent sharp uterine contractions. Why did this happen? she asks you. I didnt do anything wrong. Family Assessment Client, 20, lives in two-bedroom third-floor university housing. Undeclared major and works as a secretary in Personnel; husband (26) is a campus groundskeeper. Finances rated as, Who couldnt use more money? Client Assessment Gravida 2, para 0, 30 week pregnancy. Heart rate 88 bpm; respirations 22; blood pressure 130/78. Fetal heart rate 142 bpm; reports positive fetal movements. Uterine contractions every 7 minutes lasting 40 seconds. Intravenous tocolytic therapy with terbutaline prescribed. Nursing Diagnosis Risk for injury (maternal and fetal) related to preterm labor and tocolytic therapy Outcome Criteria Contractions halt after treatment with tocolytic; fetal heart rate remains within acceptable parameters; fetal lung maturity improves as evidenced by rising lecithinsphingomyelin ratio; client remains free of signs and symptoms of adverse effects of tocolytic therapy. Client verbalizes concerns and fears; participates in decision making and relaxation measures. Nursing Diagnosis: Situational low self-esteem related to feelings of responsibility for preterm labor Outcome Evaluation: Client expresses feelings and

worries to nurse; states it is unknown why labor began, but she knows she is not responsible for her labor beginning prematurely. A woman in preterm labor is undergoing an extreme crisis situation. She cannot help asking herself, What did I do to cause this? Time spent taking the initial history or timing contractions presents an opportunity to bring the concern out in the open: Did Dr. Smith explain to you labor sometimes begins early this way without any reason? Some women worry they did something to bring on preterm labor. Have you had any thoughts like that? A woman in preterm labor that cannot be halted needs a support person with her because she is apt to be more concerned than the average woman about labor. She needs frequent assurance during labor that she is breathing well with contractions or just that she is doing well. She may not be mentally prepared for labor because it has come unexpectedly. During the postpartum period, she may need continued reassurance. Helping rebuild self-esteem this way can better prepare her to be a parent to her preterm infant. Nursing Diagnoses and Related Interventions The nursing diagnoses used with PIH are numerous because the disease has such wide-ranging effects. Some possible nursing diagnoses are: Ineffective tissue perfusion related to vasoconstriction of blood vessels Deficient fluid volume related to fluid loss to subcutaneous tissue Risk for fetal injury related to reduced placental perfusion secondary to vasospasm Social isolation related to prescribed bed rest
Monitor Antiplatelet Therapy Promote Bed Rest.

Promote Good Nutrition. Provide Emotional Support