NURSING CARE PLAN

Cues Diagnosis Planning Implementation Rationale Evaluation

Short term: 1. Assess fetal heart rate 1. Aids in determining fetal well- At the end of the
Ineffective After 1 week of nursing (FHR) manually or being. An increased FHR may nursing interventions,
Objective: Uteroplacental intervention, the electronically, as be a compensatory reaction to
Tissue Perfusion patient will be able to: indicated. hypoxia, preterm, or placental The patient
related to abruptio.
- Reduced maternal demonstrated normal
blood and interruption of Demonstrate normal 2. Assess fetal response to central nervous system
2. BPP assists in assessing CNS
nutrition flow maternal blood central nervous system biophysical profile (BPP) function and fetal (CNS) reactivity on a
through the flow as evidenced (CNS) reactivity on a criteria or contraction contribution to amniotic fluid nonstress test (NST),
placenta by preeclampsia nonstress test (NST), stress test (CST), as volume by evaluating the free of late
free of late maternal status fetus and fetal environment decelerations and has
- Decrease in decelerations and no indicates. on five particular criteria. CST no decrease in FHR on
oxygen available decrease in FHR on the evaluates placental function the contraction stress
to the fetus contraction stress and reserves. test/oxytocin challenge
test/oxytocin challenge test (CST/OCT).
3. Assess for amniotic fluid 3. AFV testing provides for the
test (CST/OCT).
volume (AFV), as detection of
indicated. oligohydramnios.
Long term: The patient reached at
After a month of 4. Advise bedrest and 4. Activity limitation conserves full term, appropriate
nursing intervention, restriction of activities. blood that would otherwise for gestational age
the patient will reach at be transmitted to the skeletal (AGA).
full term, appropriate muscles for circulation to the
for gestational age mother's essential organs and
(AGA). the placenta.

5. Educate the mother and 5. Reduced placental blood flow

family members about results in decreased gas
the home assessment or exchange and compromised
 identifying daily fetal
movements and when
to seek immediate
medical attention.
6. Identify and educate 6.
the mother and family
members about fetal
activity factors.
7. Report signs of abruptio 7.
placentae (i.e., vaginal
bleeding, uterine
tenderness, abdominal
pain, and decreased fetal
activity).
placental health. Poor
placental perfusion may result
in a malnourished, low birth
weight newborn, as well as
preterm linked with early
delivery, abruptio placentae,
and fetal mortality. Fetal
compromise is indicated by
decreased fetal activity.
Cigarette smoking,
pharmaceuticals, drug
usage, serum glucose levels,
environmental sounds, time
of day, and the fetus's sleep-
wake cycle can all influence
fetal movement. The lady
should report a reduction in
movements or if none occur
within the next three hours.
Immediate attention and
intervention boost the
The goal is met: March
chances of a successful 7, 2022 (11:30 am)
outcome. Placental
abruption occurs when the
vascular structures that
support the placenta are
compromised. These
vascular structures supply
the fetus with oxygen and
nourishment.
8. Present contact number 8. Allows to address issues and
for the client and family misconceptions and
members to direct intervene as soon as
questions, address possible, if suggested.
changes in daily fetal
movements and
maternal condition.

9. Assist with assessing fetal 9. In the event of deteriorating

maturity and well-being maternal/fetal condition, the
using lecithin- risks of delivering a premature
sphingomyelin (L/S) ratio, newborn are balanced against
prostaglandins, estriol the risks of continuing the
levels, fetal breathing pregnancy, based on the
movements, and findings of evaluative
sequential sonography examinations of lung and
beginning at 20–26 kidney maturity, fetal growth,
weeks’ gestation. and placental functioning.
Reduced maternal volume and
vascular alterations are
associated with intrauterine
growth restriction (IUGR).

10. Utilizing ultrasonography 10. Preeclampsia is related with

assist with the decreased placental function
assessment of placental and size. The failure of the
size. maternal arteries supplying
the placenta to undergo the
physiological adaptations of a
normal pregnancy that allow
adequate placental perfusion
is a typical pathological
 hallmark of preeclampsia.

Reference:

Doenges M., Moorhouse M. & Murr A. Nurses’s Pocket Guide (Diagnoses, prioritized interventions, and rationales) 14th Edition.
[libribook.com] Nurse's Pocket Guide 14th Edition.Pdf