NURSING CARE PLAN

Patient’s Name: MRS.GWYNETH CHUA Age & Gender: 26/FEMALE Chief Complaint: Bright red vaginal
Name of Student Nurse: QUIRIMIT, DARWIN N. Birthdate: January 1, 1992 bleeding without pain.
Admitting Diagnosis: PLACENTA PREVIA Level/Block/Group: Level 2
Address: #123 POBLACION, MANGALDAN, PANGASINAN
Hospital/Area: OB RLE
Date of Confinement: February 21, 2022 Clinical Instructor: MRS. B.M.S & MRS. K.L.U Date: February 21, 2022
CASE:
A 30-year-old G5P4 woman at 32 weeks’ gestation complains of significant bright red vaginal bleeding. She denies
uterine contractions, leakage of fluid, or trauma. The patient states that 4 weeks previously, after she had engaged in
sexual intercourse, she experienced some vaginal spotting. On examination, her blood pressure is 110/60 mm Hg,
heart rate (HR) is 80 beats per minute (bpm), and temperature is 99°F (37.2°C). The heart and lung examinations are
normal. The abdomen is soft and uterus nontender. Fetal heart tones are in the range of 140 to 150 bpm.
This patient is experiencing antepartum vaginal bleeding (bleeding after 20 weeks’ gestation). Because of the painless
nature of the bleeding and lack of risk factors for placental abruption, this case is more likely to be placenta previa,
defined as the placenta overlying the internal os of the cervix. Placental abruption (premature separation of the
placenta) usually is associated with painful uterine contractions or excess uterine tone. The history of postcoital
spotting earlier during the pregnancy is consistent with previa because vaginal intercourse may induce bleeding. The
ultrasound examination is performed before a vaginal examination because vaginal manipulation (even a speculum
examination) may induce bleeding. Because the patient is hemodynamically stable, and the fetal heart tones are
normal, expectant management is the best therapy at 32 weeks’ gestation (due to the prematurity risks). If the same
patient were at 35 to 36 weeks’ gestation, delivery by cesarean section would be prudent.
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE:  - deficient fluid SHORT TERM:  Always keep an  These alterations  the goal was
“4weeks previously, volume related to  - After 1-2 hours eye on the in vital signs are attained after 1-2
after I engaged in hypovolemia as of nursing care, mother's vital related with fluid hours of nursing
sexual intercourse, I evidenced by, the patient will be signs and note volume loss or intervention, the
experienced some “4weeks able to any changes, as hypovolemia. patient verbalized
vaginal spotting.” as previously, after I compensate for well as the FHR. the compensate
verbalized by the engaged in sexual the blood loss for blood loss
patient. intercourse, I caused by the  Always make an  to acquire the caused by the
experienced some hemorrhage or effort to establish trust of the hemorrhage or
vaginal spotting.” bleeding rapport. patient bleeding.
- Rated pain as 0/10
in a pain scale of 0/10 as verbalized by
Recommend that  This activity,
the patient.  The patient's vital  The objective was
the patient refrain particularly if
signs will return fulfilled since the
from engaging in orgasm occurs,
OBJECTIVE: to normal after 8 client/patient
sexual activity may be connected
- red bright vaginal hours of nursing stated that she is
that may lead to with brief uterine
bleeding intervention. feeling better
orgasm contractions,
- vaginal spotting than before and
which might
- leakage of fluid  To reduce the risk her vital signs
 Start IV fluids as result in bleeding.
- uterine contractions of bleeding have returned to
directed by your There's also the
- trauma normal.
physician or possibility that
LONG TERM:
obstetrician vaginal
Vital Signs:  As long as the  Stop doing sextual
(specify fluid type intercourse will
BP = 100/60 mm Hg bleeding is not intercourse to
and rate) produce direct
HR = 80 bpm severe, expectant stop the bleeding.
harm to the
T = 990 F (37.20C) treatment is  recommend to
previa, resulting
FHT = 14-150 bpm appropriate. At 35 the patient to do  In 35-36 weeks,
in bleeding.
to 36 weeks' breating exercise. the client's
gestation, a placental edge
cesarean birth is  Administer the  For the covered the
performed. anesthesia to the replenishment of internal os, and a
patient since she fluid volume loss. cesarean birth
will undergo a was planned since
cesarean section.  To assist the the previa is likely
patient in to continue until
becoming more the time of birth..
relaxed and calm.

 This will assist the

patient avoid
feeling discomfort
during the
cesarean section,
often known as
CS.