There are 5 NCP on Abruptio Placenta, and is already prioritized :)Nursing Diagnosis: Fluid Volume Deficit r/t massive vaginal hemorrhage due to secondary to complete placental separationNursing Diagnosis: Impaired gas exchange: fetal r/t insufficient maternal-fetal oxygen transfer and supply secondary to premature separation of the placentaNursing 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 placentaNursing Diagnosis: risk for fetal injury r/t impaired maternal – fetal nutrition and oxygen transfer to the fetus secondary to premature placental separation.Nursing Diagnosis: Anxiety r/t maternal-fetal outcome due to the lack of knowledge about the effects of early placental separation secondary Abruptio Placenta
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Nursing Care Plan (NCP) Nursing Diagnosis: Fluid Volume Deficit r/t massive vaginal hemorrhage due to secondary to complete placental separation Cues Objective Nursing Intervention Rationale Evaluation Subjective: The patient may report: Thirst Weakness Dizziness Objective: Decreased urine output; increased urine concentration Decreased venous filling; decreased pulse volume/pressure Sudden weight loss (except in third spacing) 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/transp ort to the tissues will be stabilized. LTO: After 1-2 hrs of continuing Continuous evaluate maternal and fetal physiologic status, particularly: Vital Signs Bleeding Electronic fetal and maternal monitoring tracings Signs of shock – rapid pulse, cold and moist skin, decrease in blood pressure Decreasing urine output Never perform a vaginal or rectal examination or take any action that would stimulate uterine activity. Asses the need for immediate delivery.. On admission, place the woman on bed rest in a Alteration in vital signs can call for prompt actions. If the client is in active labor and bleeding cannot be stopped with bed rest, emergency cesarean delivery may be indicated To prevent pressure on the vena cava. for fluid replacement.
Transcript
Nursing Care Plan (NCP)Nursing Diagnosis: Fluid Volume Deficit r/t massive vaginal hemorrhage due to secondary to complete placental separation
Decreased urine output; increased urine concentrationDecreased venous filling; decreased pulse volume/pressureSudden weight loss (except in third spacing)Decreased BP; increased pulse rate/body temperatureDecreased skin/tongue turgor; dry skin/mucous membranesChange in mental state
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.
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 (<1-2
Continuous evaluate maternal and fetal physiologic status, particularly: Vital Signs Bleeding Electronic fetal and maternal
monitoring tracings Signs of shock – rapid pulse,
cold and moist skin, decrease in blood pressure
Decreasing urine output Never perform a vaginal or
rectal examination or take any action that would stimulate uterine activity.
Asses the need for immediate delivery..
On admission, place the woman on bed rest in a lateral position
Insert a large gauge intravenous catheter into a large vein for fluid replacement.
Obtain a blood sample for fibrinogen level.
Monitor the FHR externally and measure maternal vital signs every 5
Alteration in vital signs can call for prompt actions.
If the client is in active labor and bleeding cannot be stopped with bed rest, emergency cesarean delivery may be indicated
To prevent pressure on the vena cava.
for fluid replacement.
To find out the extent of hemorrhage for prompt intervention.
sec), pinkish skin, and normal blood pressure within the range of 100/80mmHG-130/90mmHg.
to 15 minutes.
Prepare for cesarean section
Provide client and family teaching.
Address emotional and psychosocial needs.
Maintain accurate I/O and weigh daily. Measure urine specific gravity. Monitor bloodpressure and invasive hemodynamic parameters as indicated (e.g., CVP, PAP/PCWP)
Change position frequently. Bathe infrequently, using mild cleanser/soap, and provideoptimal skin care with emollients
Assess and monitor vital signs; BP,PR,RR, temp
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 eye care, and skin care.
distress is detected.
the method of choice for the birth
Allows them to understand the situation
Calms client and helps her to take in the stress.
To evaluate effectiveness of resuscitation measures.
to maintain skin integrity and prevent excessive drynesscaused by dehydration.
Alterations in the vital signs may indicate that there is something wrong in the body systems.
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.
Provide safety measures such as raising the side rails and keeping sharp things away from the patient, that is, when the client is confused.
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.
To prevent tissue injury from dryness.
Protects the patient from any physical injuries.
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
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.
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.
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.
Evaluate pulse oxymetry to determine oxygenation.
Elevate head of bed or position the mother appropriately
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
Promote/provide calm, restful, and free stimulant environment.
Provide psychologic support such as listening to questions or concerns.
Administer medications as ordered by the physician.Assist with procedures as individually indicated like blood transfusion.
Position mother in left lateral position
Begin electronic fetal monitoring
Have equipment for emergency cesarean delivery readily available
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
To promote airway.
Oxygen may transfer to the fetus, thus it provides oxygen and nutrients to the fetus.
Helps limit oxygen needs or consumption of the mother
Promotes comfort to the mother
To establish rapport and trust
To treat underlying conditions
Improves respiratory function or oxygen carrying capacity.
To help in the circulation, and avoid compressing the vena cava
to continuously assess FHR
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
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
patient reports a sharp knife-like stabbing pain in her abdomen
Objective:
Protective behaviorGrimace faceCryingIrritableRestlessdiaphoresisdecrease BP (<110/70mmHG)increase RR (25bpm)increase PR (140bpm)
STO:
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.
LTO:
After 4-6hrs of monitoring patient’s vital signs, assessing pain scale, and providing comfort and safety measures together with the administration of tocolytic drugs (as ordered by the doctor), the patient’s improvements such as the reduction of pain will be maintained.
Educate patient to have a bed rest. Allow patient to be in the left side-lying position or any position that is comfortable for her.
Administer tocolytic medications as ordered.
Administer anticoagulant agents as ordered.
Measure abdominal girth.
Monitor patient’s vital signs.
Assess for referred pain, as appropriate.
Encourage verbalizations of feelings about the pain.
Provide/perform comfort measures when necessary (back rub, change of position). Provide quiet environment and calm activities.
Monitor fetal heart tone, beat, movements. If vague and absent, prepare for surgery/delivery.
Prepare blood products, IV fluids for fluid replacement from bleeding and
Increase in size that is more than normal may indicate that there is an abnormal accumulation inside the abdomen
Vital signs usually is altered acute pain
To help determine possibility of underlying condition requiring treatment.
May alleviate pain
To provide non-pharmocologic treatment.
Vagueness/absence of fetal heart tone, beat, and fetal movements may indicate fetal hypoxia/death
To replace the blood being formed to aclot and prevent replaced fluid loss
blood clotting.
Position mother in left lateral position
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
Assess the patient’s extent of
that would lead to tissue injury due to dehydration.
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
To monitor extent and condition of
bleeding and monitor fundal height q 30 mins.
Draw line at the level of the fundus and check it every 30 mins
Count the number of pads that the patient uses, weighing them as necessary
Monitor maternal blood pressure, pulse rate, respirations, central venous pressure, intake and output and amount of vaginal bleeding q 10 – 15 mins
the bleeding for prompt intervention
(if the level of the fundus increases, suspect abruptio placentae)
to determine the amount of blood loss
To determine any changes that can alter the mother’s condition, and for prompt intervention
NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 494 - 499
Nursing Care Plan (NCP)Nursing Diagnosis: risk for fetal injury r/t impaired maternal – fetal nutrition and oxygen transfer to the fetus secondary to premature placental separation.
STO:Within 20-40 minutes of administering IV fluids and oxygen supplement to the mother, the fetus will be able to receive adequate amount of oxygen and nutrients for life support.
LTO:Within 1-4hrs of letting the mother have complete bed rest, providing safety measures and promoting a clean and quiet environment, the fetus will be able to receive continuous amount of oxygen necessary for the transportation of nutrients.
Educate mother to have a complete bed rest.
Assess and monitor continuously the vital signs of the mother and the fetus.
Evaluate pulse oximetry of the mother to determine oxygen saturation in her body.
Provide/administer supplemental oxygen saturation at lowest concentration or as indicated by the laboratory results.
Administer IV fluids, as indicated.
Provide safety measures (e.g. raise side rails and keeping off things that are sharp and edgy), and promoting a clean and quiet environment.
Position mother in left lateral position
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
Bed rest helps prevent further complications and helps limit oxygen consumption.
Alterations of the vital signs of the mother and fetus from the normal values may indicate that there is something wrong in the body of the mother.
To assess respiratory insufficiency.
This provides adequate supply of oxygen to the blood of the mother while circulating, thus nutrients and oxygen will be transported to the fetus.
For nutritional support to the mother and fetus and for fluid replacement, if vaginal bleeding occurs.
To protect client from injuries and to provide the patient comfort
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
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
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 400- 406
Nursing Care Plan (NCP)Nursing Diagnosis: Anxiety r/t maternal-fetal outcome due to the lack of knowledge about the effects of early placental separation secondary Abruptio Placenta
STO: After 10-15min of assessing the patient’s perception and giving emotional support, client will be able to calm down and think that she is not alone.
LTO: After 30-60min of providing genuine information about the situation and allowing patient to raise some questions and answer it honestly, the client will be able to accept slowly the situation and the outcome.
Give support emotionally by being available and actively listening
Ascertain client’s perception of what is occurring and how this affects life.
Note degree of concentration, focus of attention.
Measure vital signs/physiologic responses to situation.
Stay with client or make some arrangements to have someone else be there.
Provide information truthfully in verbal/written form. Speak in simple sentences and concrete terms.
Provide opportunity to the patient to ask some questions and nurses must answer honestly.
Provide objective information when available when available and allow client to use it freely. Avoid arguing about client’s perceptions of the situation.
Encourage contact with a peer who has successfully dealt with similar fearful situations.
Refer to supportive groups, community agencies/organizations, as indicated.
Administer anti-anxiety medications, as ordered by physician
Provide quiet and calm environment.
Conveys acceptance and confidence in ability to cope with situation.
To measure the level of perception/consciousness of the client.
To know if patient knows the real situation.
To assess clients perception to the situation.
Sense of abandonment can exacerbate fear.
Facilitates understanding and retention to information.
Enhances sense of trust and nurse-client relationship.
Limits conflicts when fear response may impair rational thinking.
Provides a role model, and client is more likely to believe others who had similar experience.Provides ongoing assistance for individual needs.
Position mother in left lateral position
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
It helps calm the patient.
Gives comfort to patient.
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
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 62 - 67
