You are on page 1of 19

GUINITARAN, CHRISTINE ANN P.

BSN 4
ABRUPTIO PLACENTA NURSING CARE PLAN

Nursing Diagnosis: Fluid Volume Deficit r/t massive vaginal hemorrhage due to secondary to complete placental separation

Cues Planning Nursing Intervention Rationale Evaluation


Subjective: STO: Continuous evaluate maternal and Alteration in vital signs can call for
fetal physiologic status, particularly: prompt actions.
The patient may report: After 30-60 minutes of  Vital Signs
Thirst administering oxygen  Bleeding
Weakness supplement and  Electronic fetal and maternal
Dizziness performing blood monitoring tracings
transfusion, the  Signs of shock – rapid pulse, cold
patient’s blood and moist skin, decrease in blood
components that were pressure
lost will be replaced and  Decreasing urine output
the patient’s circulation  Never perform a vaginal or rectal
of blood and oxygen examination or take any action
delivery/transport to the that would stimulate uterine
tissues will be activity.
stabilized.
Objective:
Asses the need for immediate If the client is in active labor and
Decreased urine output; LTO: delivery.. bleeding cannot be stopped with bed
increased urine rest, emergency cesarean delivery
concentration After 1-2 hrs of may be indicated
Decreased venous continuing oxygen
filling; decreased pulse supplementation,
volume/pressure administering blood On admission, place the woman on To prevent pressure on the vena cava.
Sudden weight loss transfusion, and bed rest in a lateral position
(except in third spacing) providing a calm and
Decreased BP; stimulant free Insert a large gauge intravenous for fluid replacement.
increased pulse environment such as catheter into a large vein for fluid
rate/body temperature limiting the visitation replacement.
Decreased skin/tongue hours, the patient will
turgor; dry skin/mucous be able show
membranes improvements such as Obtain a blood sample for fibrinogen
Change in mental state moist skin, moist mucus level. To find out the extent of hemorrhage
Elevated hematocrit membrane, normal skin for prompt intervention.
Decreased blood turgor (<1-2 sec),
pressure (<120/80) pinkish skin, and normal Monitor the FHR externally and Allows prompt intervention if fetal
Dry skin blood pressure within measure maternal vital signs every 5 distress is detected.
Dry mucous membrane the range of to 15 minutes.
Decreased skin turgor 100/80mmHG-
(>1-2 seconds) 130/90mmHg. Prepare for cesarean section the method of choice for the birth
Increased pulse rate
Increased blood clotting Allows them to understand the
factors Provide client and family teaching. situation
increased body
temperature (>36.7- Address emotional and psychosocial Calms client and helps her to take in
37.5*C) needs. the stress.
confusion
Pallor Maintain accurate I/O and weigh To evaluate effectiveness of
daily. Measure urine specific gravity. resuscitation measures.
Monitor blood
pressure and invasive hemodynamic
parameters as indicated (e.g., CVP,
PAP/PCWP)

Change position frequently. Bathe


infrequently, using mild to maintain skin integrity and prevent
cleanser/soap, and provide excessive dryness
optimal skin care with emollients caused by dehydration.

Assess and monitor vital signs;


BP,PR,RR, temp
Alterations in the vital signs may
indicate that there is something wrong
in the body systems.
Provide fluid replacement needs and
routes to be used. Prevents peaks in fluid level.

Administer IV fluids. Administer blood


products/ plasma expanders as To replace the fluid lost in the body.
indicated.

Control humidity and ambient air


temperature and perform TSB when Humidity and air temperature affects
there is fever. any changes in the body temperature
of the client.
Provide and perform oral care and
eye care, and skin care. To prevent tissue injury from dryness.

Provide safety measures such as Protects the patient from any physical
raising the side rails and keeping injuries.
sharp things away from the patient,
that is, when the client is confused.

Provide and maintain a clean and well


ventilated room, and provide and These promote comfort to the patient.
maintain a calm and quiet
environment.

Administer antipyretics to reduce Fever further causes dryness and


fever as ordered by the physician. dehydration.

Administer oxygen supplement via


mask. Decrease in blood due to hemorrhage
means the decrease in oxygen supply
in the body. Administering oxygen via
mask provides more oxygen faster.

To prevent further complications to the


Stop blood loss: administer mother and to prevent fetal demise/
anticoagulant drugs as ordered, and death.
prepare for surgical intervention or
immediate delivery as needed.
NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 316- 319
ABRUPTIO PLACENTA NURSING CARE PLAN

Nursing Diagnosis: Impaired gas exchange: fetal r/t insufficient maternal-fetal oxygen transfer and supply secondary to premature separation of the placenta

Cues Planning Nursing Intervention Rationale Evaluation


Subjective: STO: Auscultate mother’s abdomen to hear To determine of there are any signs of
the fetal heart tone. life of the fetus inside the womb.
Within 15-30 minutes of Assess and monitor fetal heart tone,
providing oxygen beat and movement.
supplement to the To determine what appropriate
mother, thee fetus will be Assess level of consciousness of the interventions should be given
able to receive adequate mother.
oxygen from the To assess respiratory efficiency
impairment of gas Evaluate pulse oxymetry to determine
exchange and allow oxygenation.
transfer of nutrients. To promote airway.
Objective: Elevate head of bed or position the
LTO: mother appropriately
Decrease fetal heart Oxygen may transfer to the fetus, thus
tone After 30-60 minutes of Provide supplemental oxygenation at it provides oxygen and nutrients to the
Decrease fetal heart maintaining oxygen lowest concentration as indicated by fetus.
rate(70-120bpm) supplementation and laboratory results.
Decrease fetal allowing the mother to
movements have bed rest, the fetus Encourage or educate the mother to Helps limit oxygen needs or
will be able to show have adequate rest and limit activities consumption of the mother
Decrease maternal improvements such as to within client tolerance
oxygen saturation having a fetal heart rate
(93%) within the range of 120- Promote/provide calm, restful, and
160 bpm and will show free stimulant environment. Promotes comfort to the mother
active fetal movements.
Provide psychologic support such as
listening to questions or concerns. To establish rapport and trust

Administer medications as ordered by


the physician. To treat underlying conditions
Assist with procedures as individually
indicated like blood transfusion. Improves respiratory function or
oxygen carrying capacity.
Position mother in left lateral position

To help in the circulation, and avoid


Begin electronic fetal monitoring compressing the vena cava

Have equipment for emergency to continuously assess FHR


cesarean delivery readily available

Prepare the patient and family The delivery method of choice is CS


members for the possibility of an
emergency CS delivery, the delivery
of a premature neonate and the To help the SOs understand the critical
changes to expect in the postpartum condition of the mother and have
period reassurances of the mother’s current
condition
offer emotional support and an honest
assessment of the situation

tactfully discuss the possibility of To help the SOs and mother to prepare
neonatal death physically and emotionally to the
situation

-tell the mother that the neonate’s


survival depends primarily on
gestational age, the amount of blood
lost, and associated hypertensive
disorders-assure her that frequent
encourage the patient and her family monitoring and prompt management
to verbalize their feelings greatly reduce the risk of death.

Help them to develop effective coping Allowing them to understand clearly


strategies, referring them for the situation
counseling if necessary
Helps the SOs and mother cope with
the situation properly

NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 322 - 327
ABRUPTIO PLACENTA NURSING CARE PLAN
Nursing Diagnosis: Altered comfort: acute pain related to increase pressure in the abdomen and bleeding between the uterine walls due to
massive accumulation of blood clots behind the placenta secondary to premature separation of the placenta

Cues Planning Nursing Intervention Rationale Evaluation


Subjective: STO: Educate patient to have a bed rest. May relieve pain.
Allow patient to be in the left side-lying
patient reports a sharp After 45-60 minutes of position or any position that is
knife-like stabbing administering comfortable for her.
pain in her abdomen anticoagulant agents and
monitoring vital signs, the Administer tocolytic medications as
patient will be able to ordered. Tocolytic agents reduce uterine
report improvements contractility/activity.
such as the decrease of Administer anticoagulant agents as
pain in the abdomen due ordered. To decrease/reduce blood clots.
to the reduction of blood
clots formed behind the
placenta. Measure abdominal girth. Increase in size that is more than
normal may indicate that there is an
Objective: abnormal accumulation inside the
LTO: abdomen
Protective behavior
Grimace face After 4-6hrs of monitoring Vital signs usually is altered acute pain
Crying patient’s vital signs, Monitor patient’s vital signs.
Irritable assessing pain scale, To help determine possibility of
Restless and providing comfort underlying condition requiring
diaphoresis and safety measures Assess for referred pain, as treatment.
decrease BP together with the appropriate.
(<110/70mmHG) administration of tocolytic May alleviate pain
increase RR (25bpm) drugs (as ordered by the
increase PR (140bpm) doctor), the patient’s Encourage verbalizations of feelings
improvements such as about the pain. To provide non-pharmocologic
the reduction of pain will treatment.
be maintained. Provide/perform comfort measures
when necessary (back rub, change of
position). Provide quiet environment
and calm activities.
Vagueness/absence of fetal heart tone,
Monitor fetal heart tone, beat, beat, and fetal movements may
movements. If vague and absent, indicate fetal hypoxia/death
prepare for surgery/delivery.
To replace the blood being formed to
Prepare blood products, IV fluids for aclot and prevent replaced fluid loss
fluid replacement from bleeding and that would lead to tissue injury due to
blood clotting. dehydration.

To help in the circulation, and avoid


compressing the vena cava
Position mother in left lateral position
to continuously assess FHR

Begin electronic fetal monitoring


The delivery method of choice is CS
Have equipment for emergency
cesarean delivery readily available
To help the SOs understand the critical
Prepare the patient and family condition of the mother and have
members for the possibility of an reassurances of the mother’s current
emergency CS delivery, the delivery condition
of a premature neonate and the
changes to expect in the postpartum
period
To help the SOs and mother to prepare
offer emotional support and an honest physically and emotionally to the
assessment of the situation situation

tactfully discuss the possibility of -tell the mother that the neonate’s
neonatal death survival depends primarily on
gestational age, the amount of blood
lost, and associated hypertensive
disorders-assure her that frequent
monitoring and prompt management
greatly reduce the risk of death.

Allowing them to understand clearly


the situation
encourage the patient and her family
to verbalize their feelings Helps the SOs and mother cope with
the situation properly
Help them to develop effective coping
strategies, referring them for
counseling if necessary
To monitor extent and condition of the
Assess the patient’s extent of bleeding for prompt intervention
bleeding and monitor fundal height q
30 mins.
(if the level of the fundus increases,
suspect abruptio placentae)
Draw line at the level of the fundus
and check it every 30 mins to determine the amount of blood loss

Count the number of pads that the


patient uses, weighing them as To determine any changes that can
necessary alter the mother’s condition, and for
prompt intervention
Monitor maternal blood pressure,
pulse rate, respirations, central
venous pressure, intake and output
and amount of vaginal bleeding q 10 –
15 mins

NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 494 - 499
ABRUPTIO PLACENTA NURSING CARE PLAN

Nursing Diagnosis: risk for fetal injury r/t impaired maternal – fetal nutrition and oxygen transfer to the fetus secondary to premature
placental separation.

Cues Planning Nursing Intervention Rationale Evaluation


Subjective: STO: Educate mother to have a complete Bed rest helps prevent further
Patient reports Within 20-40 minutes of bed rest. complications and helps limit oxygen
abdominal discomfort administering IV fluids consumption.
(maternal). and oxygen supplement
to the mother, the fetus Assess and monitor continuously the Alterations of the vital signs of the
Objective: will be able to receive vital signs of the mother and the fetus. mother and fetus from the normal
Weak fetal heart rate adequate amount of values may indicate that there is
and tone oxygen and nutrients for something wrong in the body of the
life support. mother.
Decrease fetal Evaluate pulse oximetry of the mother
movement LTO: to determine oxygen saturation in her To assess respiratory insufficiency.
Within 1-4hrs of letting body.
Little/no vaginal the mother have
bleeding (maternal) complete bed rest, Provide/administer supplemental This provides adequate supply of
providing safety oxygen saturation at lowest oxygen to the blood of the mother
measures and promoting concentration or as indicated by the while circulating, thus nutrients and
a clean and quiet laboratory results. oxygen will be transported to the fetus.
environment, the fetus
will be able to receive Administer IV fluids, as indicated. For nutritional support to the mother
continuous amount of and fetus and for fluid replacement, if
oxygen necessary for the vaginal bleeding occurs.
transportation of
nutrients. Provide safety measures (e.g. raise To protect client from injuries and to
side rails and keeping off things that provide the patient comfort
are sharp and edgy), and promoting a
clean and quiet environment.

Position mother in left lateral position To help in the circulation, and avoid
compressing the vena cava

Begin electronic fetal monitoring to continuously assess FHR


Have equipment for emergency
cesarean delivery readily available The delivery method of choice is CS

Prepare the patient and family


members for the possibility of an To help the SOs understand the critical
emergency CS delivery, the delivery condition of the mother and have
of a premature neonate and the reassurances of the mother’s current
changes to expect in the postpartum condition
period

offer emotional support and an honest


assessment of the situation To help the SOs and mother to prepare
physically and emotionally to the
tactfully discuss the possibility of situation
neonatal death
Tell the mother that the neonate’s
survival depends primarily on
gestational age, the amount of blood
lost, and associated hypertensive
disorders-assure her that frequent
monitoring and prompt management
greatly reduce the risk of death.

encourage the patient and her family Allowing them to understand clearly
to verbalize their feelings the situation

Help them to develop effective coping Helps the SOs and mother cope with
strategies, referring them for the situation properly
counseling if necessary .

NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 400- 406
ABRUPTIO PLACENTA NURSING CARE PLAN

Nursing Diagnosis: Anxiety r/t maternal-fetal outcome due to the lack of knowledge about the effects of early placental separation
secondary Abruptio Placenta

Cues Planning Nursing Intervention Rationale Evaluation


Subjective: STO: After 10-15min of Give support emotionally by being Conveys acceptance and confidence in
Patient verbalized, assessing the patient’s available and actively listening ability to cope with situation.
“mabuhi pa ang ako perception and giving
anak?” emotional support, client Ascertain client’s perception of what is To measure the level of
Decreased self will be able to calm down occurring and how this affects life. perception/consciousness of the client.
assurance and think that she is not
alone. Note degree of concentration, focus of To know if patient knows the real
Objective: attention. situation.
Crying LTO: After 30-60min of
Pallor providing genuine Measure vital signs/physiologic To assess clients perception to the
Fatigue information about the responses to situation. situation.
Increase pulse rate situation and allowing
(120-160bpm) patient to raise some Stay with client or make some Sense of abandonment can
confused questions and answer it arrangements to have someone else exacerbate fear.
honestly, the client will be be there.
able to accept slowly the
situation and the Provide information truthfully in Facilitates understanding and retention
outcome. verbal/written form. Speak in simple to information.
sentences and concrete terms.

Provide opportunity to the patient to


ask some questions and nurses must Enhances sense of trust and nurse-
answer honestly. client relationship.

Provide objective information when


available when available and allow
client to use it freely. Avoid arguing Limits conflicts when fear response
about client’s perceptions of the may impair rational thinking.
situation.

Encourage contact with a peer who


has successfully dealt with similar Provides a role model, and client is
fearful situations. more likely to believe others who had
similar experience.
Refer to supportive groups, Provides ongoing assistance for
community agencies/organizations, as individual needs.
indicated.

Administer anti-anxiety medications,


as ordered by physician It helps calm the patient.

Provide quiet and calm environment.

Position mother in left lateral position Gives comfort to patient.

Begin electronic fetal monitoring to continuously assess FHR

Have equipment for emergency


cesarean delivery readily available
The delivery method of choice is CS

Prepare the patient and family To help the SOs understand the critical
members for the possibility of an condition of the mother and have
emergency CS delivery, the delivery reassurances of the mother’s current
of a premature neonate and the condition
changes to expect in the postpartum
period To help the SOs and mother to prepare
physically and emotionally to the
offer emotional support and an honest situation
assessment of the situation

tactfully discuss the possibility of


neonatal death
To help the SOs and mother to prepare
physically and emotionally to the
situation

Tell the mother that the neonate’s


survival depends primarily on
gestational age, the amount of blood
lost, and associated hypertensive
encourage the patient and her family disorders-assure her that frequent
to verbalize their feelings monitoring and prompt management
greatly reduce the risk of death.
Help them to develop effective coping
strategies, referring them for Allowing them to understand clearly
counseling if necessary the situation

Helps the SOs and mother cope with


the situation properly

NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 62 - 67
PLACENTA PREVIA NURSING CARE PLAN

Nursing Diagnosis: Fluid Volume Deficit r/t blood loss secondary to low Placental Implantation

Cues Planning Nursing Intervention Rationale Evaluation


Subjective:
Short Term: Assess Vital Signs (pulse, Provides baseline data on maternal Short Term:
“nag spotting ko” as respirations, and blood pressure blood loss.
verbalized by the After 4 hours of nursing every 15 minutes). The patient
patient intervention, the patient shall have
will verbalize Maintain bed rest or chair rest when Systemic rest is mandatory and verbalized
understanding of indicated. Provide frequents rest important throughout all phases of understanding
causative factors. periods and uninterrupted night time disease to reduce fatigue and improve of causative
sleep. strength. factors.

Objective: Long Term: Monitor color, odor, consistency, Provide objective evidence of bleeding.
amount and type of bleeding; weigh Long Term:
Slightly pale pads
After 4 days of nursing
Cold , Clammy skin
interventions, the The patient
Low Blood Pressure Position mother on her left side. To improve placental perfusion.
patient will maintain shall have
Increased Heart rate
fluid volume at a maintained
Body weakness Assess hourly intake and output. Provides information about maternal
functional level AEB fluid volume
Fetal Heart Rate less and fetal physiologic compensation to
individually adequate at a functional
than normal blood loss.
urinary output and level AEB
Bleeding episodes
stable vital signs. individually
Decreased urine output Restrict vaginal examination. Prevents tearing of placenta if placenta
adequate
Abdomen soft/hard previa is the cause of bleeding.
urinary output
when palpated
and stable
Assess fetal heart tone. Assess whatever labor is present and
vital signs.
fetal status and external system avoids
cervical trauma.

Assess abdomen for tenderness or Detecting increased in measurement of


rigidity- if present, measure abdomen abdominal girth suggests active
at umbilicus (specify time interval) abruption
Assess SaO2, skin color, temp, Assessment provides information
moisture, turgor, capillary refill about blood vol., O2 saturation and
(specify frequency) peripheral perfusion

Assess for changes in LOC: note for To detect signs of cerebral perfusion
complaints of thirst or apprehension

Provide supplemental O2 as ordered Intervention increases available O2 to


via face mask or nasal cannula @ 10- saturate decreased hemoglobin
12 L/min.

Initiate IV fluids as ordered (specify For replacement of fluid volume loss


fluid type and rate).

Position Pt. in supine with hips Position decreases pressure


elevated if ordered or left lateral on placenta and cervical os.
position. Left position improves placental
perfusion.

Monitor lab. Work as obtained: Hgb & Lab Work provides information about
Hct, Rh and type, cross match for 2 degree of blood loss; prepares for
units RBCs, urinalysis, etc. possible transfusion. Ultrasound
Scheduled for ultrasound as ordered. provides info about the cause
of bleeding
PLACENTA PREVIA NURSING CARE PLAN

Nursing Diagnosis: Decreased cardiac output r/t altered contractility

Cues Planning Nursing Intervention Rationale Evaluation


Short Term:
Dysrhythmias Short Term: Establish Rapport To gain patient’s trust
The patient
prolonged capillary refill After 4 hours of nursing Monitor Vital Signs To obtain baseline data shall have
interventions, the participated in
cold clammy skin patient will participate in History taking To determine contributing factors activities that
activities that reduce reduce the
Dyspnea the workload of the Assess patient condition To assess contributing factors workload of
heart. the heart.
Restlessness Review lab data For comparison with current normal
values
variations in BP Long Term: Long Term:
readings Monitor BP & Pulse frequently To note response to activity
After 4 days of nursing The patient
Provide information on test To gain patient’s participation
interventions, the shall have
Procedures
patient will manifest manifested
hemodynamic stability. hemodynamic
Provide adequate rest & Reposition To promote venous return
stability
client

Encourage relaxation techniques To alleviate stress & anxiety

Elevate HOB To promote circulation

Encourage use of relaxation To decrease tension level


techniques
PLACENTA PREVIA NURSING CARE PLAN

Nursing Diagnosis: Ineffective tissue perfusion r/t decreased HgB concentration in blood & hypovolemia secondary to placenta
previa

Cues Planning Nursing Intervention Rationale Evaluation


Short Term:
Short Term: Establish Rapport To gain patient’s trust
Restlessness The patient
After 4 hours of nursing Monitor Vital Signs To obtain baseline data shall have
interventions, the demonstrated
Confusion patient will demonstrate Assess patient condition To assess contributing factors behaviors to
behaviors to improve improve
circulation. Note customary baseline data (usual For comparison with current findings circulation.
Irritability
BP, weight, lab values)
Long Term: Determine presence of dysrhythmias To identify alterations from normal Long Term:
Manifest Body
Weakness
Perform blanch test To identify / determine adequate
After 4 days of nursing The patient
perfusion
interventions, the shall have an
patient will demonstrate increased
Check for Homan’s Sign To determine presence of thrombus
increased perfusion as perfusion as
formation
individually appropriate individually
appropriate.
Encourage quiet & restful To lessen O2 demand
environment

Elevate HOB To promote circulation

Encourage use of relaxation To decrease tension level


techniques
PLACENTA PREVIA NURSING CARE PLAN

Nursing Diagnosis: Acute Pain at the back related to increasing weight of gravid uterus.

Cues Planning Nursing Intervention Rationale Evaluation


Subjective:
At the end of 30 INDEPENDENT
“sakit akong likod” as minutes nursing
verbalized by the interventions, the Advice the client, partner or Early intervention may decrease the
patient patient will verbalize significant others to anticipate the total amount of analgesic required.
adequate relief of pain. need for pain relief.

Provide rest periods to facilitate The patient’s experiences of pain may


comfort, sleep and relaxation become exaggerated as the result of
Objective: fatigue.

Uneasy Instruct the client to verbalize pain in To be able to determine the type or
scale 1-10. level of care to be given.

Provide comfort measures such as To relieve or reduce pain into tolerable


massage at the site of pain. scale.

DEPENDENT

Give analgesic as ordered, evaluating Pain medications are absorbed and


effectiveness and observing for any metabolized differently by patients so
signs and symptoms for untoward their effectiveness must be evaluated
effect. from patient to patient.
PLACENTA PREVIA NURSING CARE PLAN

Nursing Diagnosis: Impaired urinary elimination related to changes in usual voiding pattern.

Cues Planning Nursing Intervention Rationale Evaluation


Subjective:
At the end of 8 hours of Monitor urinary elimination including These parameters help determine
“sige lang ko ug ihi-ihi” nursing interventions, consistency, color, odor and volume. adequacy of urinary tract function.
as verbalized by the the patient’s voiding
patient pattern will be
normalized. Instruct her to drink a minimum of Increased fluids during the day will
1,500 ml (six to eight ounce glasses) increase urinary output and discourage
fluid per day. bacterial growth.

Objective: Alcohol, coffee, chocolate, Sodas and


Limit ingestion of bladder irritants tea have a natural diuretic effect and
Urinated 10 times a day (coffee, colas, tea and chocolate). are bladder irritants.