UNIVERSIDAD DE DAGUPAN

SCHOOL OF HEALTH SCIENCES

Arellano St., Dagupan City, Pangasinan

NCM109_A-RLE – Care of Mother, Child at Risk or with Problems,

(ACUTE AND CHRONIC)
2nd Semester | S.Y. 2021-2022

Submitted to the
Faculty of the College of Nursing

In partial fulfillment of the requirements of the

course: NCM 109_A-RLE

By:

PEREGRINO, JOYCE ANN P.

 UNIVERSIDAD DE DAGUPAN
SCHOOL OF HEALTH SCIENCES
Arellano St., Dagupan City, Pangasinan

NURSING CARE PLAN

Name: Joyce Ann P. Peregrino Date: June 17, 2022 Inclusive Dates of Rotation: ______ _
Year & Block: 22-BSN-01 Shift/Days: Clinical Instructor: Prof. Maria Myline Aquino

ABRUPTIO PLACENTAE
Case Scenario:

A 22 year old gravida 4 para 3303 Caucasian woman carrying a singleton pregnancy at 35 weeks estimated gestational age presents to the emergency room with vaginal bleeding,
“I felt like my underwear was wet and when I looked at it, I saw there was blood on it.” the patient said. She has had limited prenatal care and she reports that she is approximately
36 weeks estimated gestational age by dates. Her records indicate she is carrying a singleton pregnancy in the vertex presentation. Her past medical history is uncomplicated, she
has no allergies, and she takes no medications other than prenatal vitamins. Her prenatal labs are not available. She states that her pregnancy has been uncomplicated with the
exception of occasional spotting in the last trimester. She is uncertain if she has experienced rupture of membranes. An external fetal monitor is in place.
Physical examination reveals:
• Vital signs heart rate = 132 beats per minute, blood pressure 135/80 mm Hg
• Uterus: longitudinal fetal lie, vertex presentation
• Cervix: dilatation 2 cm, effacement 40%, station -2, small amounts of bright red blood per vagina are noted

Patient’s Name (Optional)/ Case Number:

NURSING DIAGNOSIS: Risk for Shock related to external or internal bleeding as evidenced by vaginal bleeding
Medical Diagnosis: Abruptio Placentae
Expected Outcome:
 Patient will display hemodynamic stability.
 Patient will regain vital signs within the normal range.
 Patient will be able to verbalize understanding of disease process, risk factors, and treatment plan.
 Patient will display a normal central venous pressure.
 Patient’s skin is warm and dry.
 Fetal heart rate is within normal range.
 Patient will exhibit an adequate amount of urine output with normal specific gravity.
 Patient will display the usual level of mentation.
Target Date: June 17, 2022

ASSESSMENT
Subjective: Independent:
 “I felt like my underwear
was wet and when I
looked at it, I saw there
was blood on it.” The
patient verbalized.
Objective:
 Vital Signs:
BP = 135/80 mmHg
HR = 132 beats per
minute
 Uterus: longitudinal fetal
lie, vertex presentation
 Cervix: dilatation 2 cm,
effacement 40%, station
-2, small amounts of
bright red blood per
vagina are noted
UNIVERSIDAD DE DAGUPAN
SCHOOL OF HEALTH SCIENCES
Arellano St., Dagupan City, Pangasinan
IMPLEMENTATION
1) Assess for history or
presence of conditions
leading to hypovolemic
shock.
2) Monitor for persistent or
heavy fluid or blood loss.
3) Assess vital signs and
tissue and organ perfusion.
4) Review laboratory data.
5) Monitor uterine
contractions and fetal heart
rate by external monitor.
RATIONALE
Short Term:
1) The condition may deplete
the body’s circulating
blood volume and the
ability to maintain organ
perfusion and function.
2) The amount of fluid or
blood loss must be noted to
determine the extent of
shock.
3) For changes associated
with shock states.
Long Term:
4) To identify potential
sources of shock and
degree of organ
involvement.
5) Assesses whether labor is
present and fetal status;
external system avoids
cervical trauma.
EVALUATION DATE ACHIEVED
 June 17, 2022 (13:00)
 After 4 hours of nursing
intervention, the patient
verbalized understanding
of condition, therapy
regimen, side effects of
medication, and when to
contact health care
provider. The patient was
also able to demonstrate
use of relaxation skills,
and other methods to
promote comfort.
 After 2 days of nursing
intervention, the patient
demonstrated lifestyle
changes/behaviors that
will improve circulation.
GOAL MET
 UNIVERSIDAD DE DAGUPAN
SCHOOL OF HEALTH SCIENCES
Arellano St., Dagupan City, Pangasinan

6) Measure intake and output. 6) Enables assessment of

renal function.

7) Measure maternal blood

loss by weighing perineal 7) Provides objective
pads and save any tissue evidence of amount
that has passed. bleeding.

8) Maintain a positive attitude 8) Supports mother-child

about fetal outcome. bonding.

9) Provide emotional support 9) Assists problem solving

to the woman and her which is lessened by poor
support person. self-esteem.

Dependent:

1) Collaborate in prompt 1) To maximize systemic

treatment of underlying
conditions and prepare for
or assist with medical and
surgical interventions.
2) Specializes in pregnancy,
2) Collaborate with an
Obstetrician-Gynecologist,
as indicated.
circulation and tissue and
organ perfusion.
childbirth and can provide
a wide range of services
that meet her health needs.
Will be helpful in creating
individual plans
incorporating specific
needs/restrictions.
 UNIVERSIDAD DE DAGUPAN
SCHOOL OF HEALTH SCIENCES
Arellano St., Dagupan City, Pangasinan

3) Administer oxygen by 3) To maximize oxygenation

appropriate route as of tissues.
ordered.
4) To rapidly restore or
4) Administer blood or blood sustain circulating volume
products as indicated. and electrolyte balance.

5) Withhold oral fluid 5) Anticipates need for

emergency surgery.
6) Administer Oxytocin as
ordered. 6) To control bleeding

______________________________________________ __________________________________________________
Patient/ Significant Other’s Signature Student Nurse’s Signature