Nursing Care Plans (NCP) of Abruptio Placenta

Nursing Care Plan (NCP) Nursing Diagnosis: Fluid Volume Deficit r/t massive vaginal hemorrhage due to secondary to complete placental separation Cues Subjective: The patient may report: Thirst Weakness Dizziness

Objective STO: After 30-60 minutes of administering oxygen supplement and performing blood transfusion, the patient’s blood components that were lost will be replaced and the patient’s circulation of blood and oxygen delivery/transport to the tissues will be stabilized.

Objective: Decreased urine output; increased urine concentration Decreased venous filling; decreased pulse volume/pressure Sudden weight loss (except in third spacing) Decreased BP; increased pulse rate/body temperature Decreased skin/tongue turgor; dry skin/mucous membranes Change in mental state

LTO: After 1-2 hrs of continuing oxygen supplementation, administering blood transfusion, and providing a calm and stimulant free environment such as limiting the visitation hours, the patient will be able show improvements such as moist skin, moist mucus membrane, normal skin turgor (36.737.5*C) confusion Pallor

sec), pinkish skin, and normal blood pressure within the range of 100/80mmHG130/90mmHg.

measure maternal vital signs every 5 to 15 minutes.

distress is detected.

Prepare for cesarean section

the method of choice for the birth

Provide client and family teaching.

Allows them to understand the situation

Address emotional and psychosocial needs.

Calms client and helps her to take in the stress.

Maintain accurate I/O and weigh daily. Measure urine specific gravity. Monitor blood pressure and invasive hemodynamic parameters as indicated (e.g., CVP, PAP/PCWP)

To evaluate effectiveness of resuscitation measures.

Change position frequently. Bathe infrequently, using mild cleanser/soap, and provide optimal skin care with emollients

to maintain skin integrity and prevent excessive dryness caused by dehydration.

Assess and monitor vital signs; BP,PR,RR, temp Alterations in the vital signs may indicate that there is something wrong in the body systems. Provide fluid replacement needs and routes to be used. Administer IV fluids. Administer blood products/ plasma expanders as indicated. Control humidity and ambient air temperature and perform TSB when there is fever. Provide and perform oral care and

Prevents peaks in fluid level. To replace the fluid lost in the body.

Humidity and air temperature affects any changes in the body temperature of the client.

eye care, and skin care.

To prevent tissue injury from dryness.

Provide safety measures such as raising the side rails and keeping sharp things away from the patient, that is, when the client is confused.

Protects the patient from any physical injuries.

Provide and maintain a clean and well ventilated room, and provide and maintain a calm and quiet environment. Administer antipyretics to reduce fever as ordered by the physician. Administer oxygen supplement via mask.

Stop blood loss: administer anticoagulant drugs as ordered, and prepare for surgical intervention or immediate delivery as needed.

These promote comfort to the patient.

Fever further causes dryness and dehydration.

Decrease in blood due to hemorrhage means the decrease in oxygen supply in the body. Administering oxygen via mask provides more oxygen faster. To prevent further complications to the mother and to prevent fetal demise/ death.

NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 316- 319

Nursing Care Plan (NCP) Nursing Diagnosis: Impaired gas exchange: fetal r/t insufficient maternal-fetal oxygen transfer and supply secondary to premature separation of the placenta Cues

Objective

Subjective:

STO:

Objective:

Within 15-30 minutes of providing oxygen supplement to the mother, thee fetus will be able to receive adequate oxygen from the impairment of gas exchange and allow transfer of nutrients.

Decrease fetal heart tone Decrease fetal heart rate(70-120bpm) Decrease fetal movements Decrease maternal oxygen saturation (93%)

Nursing Intervention Auscultate mother’s abdomen to hear the fetal heart tone. Assess and monitor fetal heart tone, beat and movement. Assess level of consciousness of the mother.

To determine of there are any signs of life of the fetus inside the womb. To determine what appropriate interventions should be given To assess respiratory efficiency

Evaluate pulse oxymetry to determine oxygenation. To promote airway. Elevate head of bed or position the mother appropriately

LTO: After 30-60 minutes of maintaining oxygen supplementation and allowing the mother to have bed rest, the fetus will be able to show improvements such as having a fetal heart rate within the range of 120-160 bpm and will show active fetal movements.

Rationale

Provide supplemental oxygenation at lowest concentration as indicated by laboratory results. Encourage or educate the mother to have adequate rest and limit activities to within client tolerance

Oxygen may transfer to the fetus, thus it provides oxygen and nutrients to the fetus. Helps limit oxygen needs or consumption of the mother

Promote/provide calm, restful, and free stimulant environment.

Promotes comfort to the mother

Provide psychologic support such as listening to questions or concerns.

To establish rapport and trust

Administer medications as ordered by the physician. Assist with procedures as individually indicated like blood transfusion. Position mother in left lateral position

To treat underlying conditions Improves respiratory function or oxygen carrying capacity.

Evaluation

Begin electronic fetal monitoring Have equipment for emergency cesarean delivery readily available Prepare the patient and family members for the possibility of an emergency CS delivery, the delivery of a premature neonate and the changes to expect in the postpartum period offer emotional support and an honest assessment of the situation tactfully discuss the possibility of neonatal death

encourage the patient and her family to verbalize their feelings Help them to develop effective coping strategies, referring them for counseling if necessary

To help in the circulation, and avoid compressing the vena cava to continuously assess FHR The delivery method of choice is CS To help the SOs understand the critical condition of the mother and have reassurances of the mother’s current condition

To help the SOs and mother to prepare physically and emotionally to the situation -tell the mother that the neonate’s 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. Allowing them to understand clearly the situation

Helps the SOs and mother cope with the situation properly NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 322 - 327

Nursing Care Plan (NCP) Nursing Diagnosis: Altered comfort: acute pain related to increase pressure in the abdomen and bleeding between the uterine wall due to massive accumulation of blood clots behind the placenta secondary to premature separation of the placenta Cues Objective Nursing Intervention Rationale Evaluation Subjective:

STO:

patient reports a sharp knife-like stabbing pain in her abdomen

After 45-60 minutes of administering anticoagulant agents and monitoring vital signs, the patient will be able to report improvements such as the decrease of pain in the abdomen due to the reduction of blood clots formed behind the placenta.

Educate patient to have a bed rest. Allow patient to be in the left sidelying position or any position that is comfortable for her. Administer tocolytic medications as ordered. Administer anticoagulant agents as ordered. Measure abdominal girth.

Objective: Protective behavior Grimace face Crying Irritable Restless diaphoresis decrease BP (