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BSN 4
ABRUPTIO PLACENTA NURSING CARE PLAN
Nursing Diagnosis: Fluid Volume Deficit r/t massive vaginal hemorrhage due to secondary to complete placental separation
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.
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
tactfully discuss the possibility of To help the SOs and mother to prepare
neonatal death physically and emotionally to the
situation
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
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.
NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 494 - 499
Position mother in left lateral position To help in the circulation, and avoid
compressing the vena cava
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
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
NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 62 - 67
Nursing Diagnosis: Fluid Volume Deficit r/t blood loss secondary to low Placental Implantation
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.
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
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.
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.
DEPENDENT
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.