Name of Patient: GGV______________________________________________________ Age/Sex: 47-F__________ Rm.

/Bed #: 212 – 1_________________

Chief Complaint: Painless pinkish bleeding_______________________________ Physician: Dr. Sy Tau____________________________________________
Diagnosis: Placenta Previa_________________________________________________________________________________________________________

DATE/TIME CUES NEED NURSING DIAGNOSIS GOAL OF CARE INTERVENTIONS IMPLEMENTATION EVALUATION
S
M Objective: N Deficient fluid volume r/t That within the 1.Monitor vital signs 1
A U Active blood loss as 8hours nursing @3PM
R VS – T: 37.2 T evidenced by Decrease in intervention, the R: Provides baseline 2
C PR: 95 R blood pressure patient: data on maternal
H RR: 14 I blood loss. 3
BP: 100/80 T R: a. demonstrat
23, I e improve 2. Monitor amount and 4
FHR – 110 O Fluid volume deficit is a fluid type of bleeding
2 N state in which an individual balance as 6
0 Grade 2 Bleeding – A is experiencing decreased evidenced R: Provide objective
2 mild haemorrhage L intravascular, interstitial by stable evidence of bleeding 7
0 amount with episodes / and/or intracellular fluid. vital signs.
of uterine contractions M Active blood loss or b. explain 3. Monitor hourly
@7AM E haemorrhage due to measures intake and output
Pinkish bleeding T disrupted placental that can be
A implantation during taken to R: Provides
I/O – Intake: 600cc B pregnancy may manifest treat or information about Prince Carl
Output: 350cc O signs and symptoms of fluid prevent maternal and fetal Magluyan, St. N.
L volume deficit that may later fluid physiologic
Cold and clammy I lead to hypovolemic shock volume compensation to blood
extremities C and cause maternal and loss loss.
fetal death. c. describe
AOG – 37weeks symptoms 4. Maintain bed rest
FH – 34cm Reference: that and provide frequent
Subjective: Vera, Matt. (2019, June 2). indicate rest periods and
Maternal and the need to uninterrupted sleep.
“Pakiabot ko sa tubig Newborn Care Plans. consult
nurse bi, wala juy 3 Placenta Previa with health R: Systemic rest is
kusog akong lawas Nursing Care Plans. care mandatory and
ilihok.” as verbalized Retrieved on March provide important throughout
by the pt. 23, 2020. Retrieved all phases of disease
from to reduce fatigue, and
https://nurselabs.com improve strength.
/3-placenta-previa-
nursng-care-plans/ 5. Assess skin color,
temperature, moisture,
turgor, and capillary
refill.

R: Assessment
provides information
about blood volume
and peripheral
perfusion.

6. Position mother on
her left side

R: To promote
placental perfusion

7. Monitor uterine
contractions and fetal
heart rate

R: Assess whether
labor is present and
fetal status and
external system
avoids trauma.

8. Assess for changes

in loss of
consciousness (LOC):
note for complaints of
thirst or apprehension

R: To detect signs of
cerebral perfusion

9. Assess abdomen
for tenderness or
rigidity if present,
measure abdomen at
umbilicus (specify
interval)

R: Detecting increased
in measurement of
abdominal girth
suggests active
abruption.

10. Administer IV
fluids as ordered.

R: For replacement of
fluid volume loss.

Reference:

RNpedia. (2019).
Nursing Notes.
Maternal and
Child Nursing
(Notes).
Placenta Previa
Nursing Care
Plan &
Management.
Retrieved on
March 23,
2020. Retrieved
from
https://rnpedia.c
om/nursing-
notes/maternal-
and-child-
nursing-
 notes/placenta-
previa/
REFERENCE/S:
DATE/TIME CUES NEED NURSING DIAGNOSIS GOAL OF CARE INTERVENTIONS IMPLEMENTATIONS EVALUATION