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Needs/ Problems/ Cues I. Physiologic A.Deficit Objective: -abdominal guarding -muscle tension -irritability Vital signs: T: 37.

3 P: 95 R: 22 BP: 100/70 Subjective: Nakapamati ko ug sakit sa akong pus-on, bisan ika-20 nga simana

Nursing Diagnosis Acute pain related to accumulation of blood between uterine wall and placenta

Scientific Basis Abruptio placenta refers to the premature serparation of the normally implanted placenta from the uterine wall. Blood vessels at the placental bed rupture spontaneously. It occurs when there is heavy maternal bleeding and may necessitate termination of the pregnancy.

Objectives Nursing of Care Intervention After 8 hour of nursing care, the mother will demonstra te use of relaxation skills, and other methods to promote comfort. Interventions to promote comfort:

Rationale

1. Monitor amount 1. To measure the of blood by amount of blood weighing all pads. loss. 2. Investigate reports, noting location, duration, intensity (010scale) and characteristics (dull, sharp, constant). 3. Monitor maternal vital signs and fetal heart rate through continuous monitoring. 2. Changes in location or intensity are not uncommon buy may reflect developing complications. 3. Early recognition of possible adverse effect allows for prompt interventions.

pa sa akong pagbuntis as verbalized by the mother.

Source: Straight As in MaternalNeonatal Nursing 2nd Edition, Lippincott. P114-115

4. Measure and record fundal height.

4. Fundal height may increase with concealed bleeding.

5. Position the 5. To enhance mother in a sideplacental lying position, with perfusion. the head of the bed elevated. 6. Provide comfort measure, like back rubs, deep breathing. Instruct in relaxation or visualization Source: Delmars Maternal-Infant Nursing Care Plans 2nd Edition 6. Promotes relaxation and may enhance patients coping ability by refocusing.