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NURSING CARE PLAN

ABRUPTIO PLACENTA
AND PLACENTA PREVIA

NCM 109 RLE CLINICAL

Saturday 7:00 AM – 12:00 PM

Submitted by:
REGALA, BIANCA YSABELLE M.
BSN II – B
Group 3
ABRUPTIO PLACENTA
Name: Louisse Natasha Valeria Age: 28 years old Sex: Female

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Ineffective tissue After 8 hours of Independent: After 8 hours of nursing

perfusion related nursing intervention intervention the patient
- Assess patient’s - For baseline data.
to excessive the patient will shows a sign that she
vital signs, O2
“Sobrang sakit po ng blood loss normalize her blood normalize her blood volume,
saturation, and skin
abdomen ko simula pa po volume, show shows improvement in
color.
kagabi, saka po grabe po improvement in tissue perfusion and
dinudugo ako,” as tissue perfusion and normalize the FHR of the
- Monitor for - These conditions may
verbalized by the patient. normalize the FHR of fetus.
restlessness, indicate decreased cerebral
the fetus.
anxiety, hunger and perfusion
Objective: changes in LOC.

- Monitor accurately - To obtain data about renal

 Loss of blood I&O. perfusion and function and
 FHR pattern the extent of blood loss.
 Altered BP
compared to
baseline - Monitor FHT - To provide information
 Altered PR Severe continuously regarding fetal distress
abdominal pain and/or worsening of
and rigidity condition
 Pallor
 Changes in LOC - Assess uterine - To determine the severity of
 Decrease urine irritability, the placental abruptio and
output abdominal pain and bleeding.
 Edema rigidity.
 Delay in wound
healing
 Positive Homan’s - Assess skin color,
- To determine peripheral
sign temperature,
tissue perfusion like
 Skin temperature moisture, turgor,
capillary refill. hypervolemia.
changes
 Vital signs taken
as follows:
- Elevate extremity - Helps promote circulation.
BP= 100/70mmHg
above the level of
PR= 100bpm
the heart.
RR= 18cpm
Temperature= 37.8⁰
- Teach patient not to - Uterine pressure can cause
apply uterine pooling of venous blood in
pressure. lower extremities.

- Instruct patient - To immediately provide

and/or SO to report additional interventions
immediately signs
and symptoms of
thrombosis: (1) pain
in leg, groin (2)
unilateral leg
swelling (3) pale skin
Name: Kierra Valeria Ynares Age: 27 years old Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Risk for Shock After 8 hours of  Assess for history or - The condition may After 8 hours of effective
related to the effective nursing presence of deplete the body’s nursing intervention the
“Masakit po ang tiyan ko conditions leading
separation of the intervention the circulating blood patient was able to:
saka po ang lakas po ng to hypovolemic
placenta. patient will: volume and the
dugo ko.” as verbalized by shock.  Display
ability to maintain
the patient.  Display hemodynamic
organ perfusion and
hemodynamic stability
function.
stability  Regain vital signs
Objective:  Regain vital  Monitor for within the normal
- The amount of fluid
signs within persistent or heavy range.
or blood loss must be
the normal fluid or blood loss.  Verbalize
 Vaginal Bleeding noted to determine
range. understanding of
 Increased pulse the extent of shock.
 Verbalize disease process, risk
rate understanding  Assess vital signs factors, and
 Decreased blood - For changes
of disease and tissue and treatment plan.
associated with
pressure process, risk organ perfusion.  Display a normal
shock states
 Increased factors, and central venous
respiratory rate treatment pressure.
 Decreased central plan.
 Review laboratory
 Patient’s skin is
venous pressure  Display a - To identify potential warm and dry.
data. sources of shock and
 Decreased urine normal  Fetal heart rate is
central degree of organ within normal
output
involvement.
 Decreasing level venous range.
of consciousness pressure.  Exhibit an adequate
 Collaborate - To maximize
 Cold, clammy skin  Patient’s skin amount of urine
in prompt systemic circulation
 Fetal bradycardia is warm and
treatment of
output with normal
dry. and tissue and organ specific gravity.
 Vital Signs taken underlying
as follows: perfusion.
conditions and
BP= 100/70 mmHg  Fetal heart prepare for or assist
Display the usual level of
PR= 98 bpm rate is within with medical and
mentation.
RR= 32 cpm normal range. surgical
Temperature= 37.6⁰  Exhibit an interventions.
adequate
amount of  Administer oxygen - To maximize
urine output by appropriate oxygenation of
with normal route. tissues.
specific
gravity.
 Display the  Administer blood or - To rapidly restore or
usual level of blood products as sustain circulating
mentation. indicated. volume and
electrolyte balance.

 Monitor - Assesses whether

uterine contractions labor is present and
and fetal heart rate fetal status; external
by external monitor. system avoids
cervical trauma.

 Withhold oral fluid. - Anticipates need for

emergency surgery.

 Measure maternal - Provides objective

blood loss by evidence of amount
weighing perineal bleeding.
pads and save any
tissue that has
passed.
 Maintain a positive - Supports mother-
attitude about fetal child bonding.
outcome.

 Provide emotional - Assists problem

support to the solving which is
woman and her lessened by poor
support person. self-esteem.
PLACENTA PREVIA
Name: Avianna Rye Diaz Age: 28 years old Sex: Female

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Impaired fetal After 8 hours of Independent: After 8 hours of nursing

gas exchange nursing interventions, the patient
“Bigla na lang akong 1. Establish rapport - To gain patient’s
related to altered interventions, the was able to verbalize
dinugo,” as verbalized by trust and
blood flow and patient will verbalize understanding of causative
the patient. cooperation.
decreased understanding of factors and appropriate
surface area of causative factors and interventions.
2. Monitor and assess Vital - Provide baseline data
Objective: gas exchange of appropriate
signs (pulse, respirations, on maternal blood
site of placental interventions.
temperature and blood loss.
detachment.
pressure every 15 minutes)
 Changes in fetal
heart rate or fetal
activity 3. Maintain bed rest or chair - Systematic rest is
 Release of rest when indicated. Provide mandatory and
meconium frequent rest periods and important
 Vital Signs taken as uninterrupted night time throughout all
follows: sleep. phases of disease to
BP= 100/80 mmHg reduce fatigue, and
PR= 96 bpm improve strength.
RR= 22 cpm
Temperature= 36.9⁰
4. Monitor amount and type - Provide objective
of bleeding evidence of bleeding.

5. Position mother on her - To promote placental

left side. perfusion.
6. Restrict vaginal - Prevents tearing of
examination. placenta if placenta
previa is the cause of
bleeding.

7. Monitor uterine - Assess whether labor

contractions and fetal heart is present and fetal
rate by external monitor. status and external
system avoids
cervical trauma.

8. Maintain positive attitude - Supports mother and

towards the fetal outcome. child bonding.

Collaborative:
1. Administer oxygen as - Provides adequate
indicated. fetal oxygenation
despite of lowered
maternal circulating
volume.

-
Name: Samantha Maureen Vera Age: 29 years old Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Decreased After 8 hours of Independent: After 8 hours of effective

“Wala akong cardiac output effective nursing  Establish Rapport - To gain patient’s nursing intervention the
nararamdamang masakit trust
related to altered intervention the client was able to participate
pero dinudugo kasi ako
eh,” as verbalized by the contractility client will able to  Monitor Vital Signs - To obtain baseline and demonstrate activities
patient. data
participate and that reduce the workload of
demonstrate the heart and will manifest
Objective:  History taking - To determine
activities that reduce hemodynamic stability.
contributing factors
the workload of the
 dysrhythmias
heart and will  Assess patient - To assess
 prolonged contributing factors
condition
capillary refill manifest
 cold clammy skin
hemodynamic  Review lab data - For comparison with
 Dyspnea
current normal
 restlessness stability.
values
 variations in BP
reading
 Monitor BP & Pulse - To note response to
 Vital Signs taken frequently
as follows: activity
BP= 110/170 mmHg
PR= 86 bpm  Provide information - To gain patient’s
RR= 129 cpm on test procedures participation
Temperature= 36.8⁰
 Provide adequate - To promote venous
rest & Reposition return
client
- To alleviate stress &
 Encourage anxiety
relaxation
techniques

 Elevate HOB - To promote

circulation

 Encourage use of - To decrease tension

relaxation level
techniques