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BSN 4
ABRUPTIO PLACENTA NURSING CARE PLAN
Nursing Diagnosis: Fluid Volume Deficit r/t massive vaginal hemorrhage due to secondary to complete placental separation
Provide safety measures such as Protects the patient from any physical
raising the side rails and keeping injuries.
sharp things away from the patient,
that is, when the client is confused.
Nursing Diagnosis: Impaired gas exchange: fetal r/t insufficient maternal-fetal oxygen transfer and supply secondary to premature separation of the placenta
tactfully discuss the possibility of To help the SOs and mother to prepare
neonatal death physically and emotionally to the
situation
NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 322 - 327
ABRUPTIO PLACENTA NURSING CARE PLAN
Nursing Diagnosis: Altered comfort: acute pain related to increase pressure in the abdomen and bleeding between the uterine walls due to
massive accumulation of blood clots behind the placenta secondary to premature separation of the placenta
tactfully discuss the possibility of -tell the mother that the neonate’s
neonatal death 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.
NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 494 - 499
ABRUPTIO PLACENTA NURSING CARE PLAN
Nursing Diagnosis: risk for fetal injury r/t impaired maternal – fetal nutrition and oxygen transfer to the fetus secondary to premature
placental separation.
Position mother in left lateral position To help in the circulation, and avoid
compressing the vena cava
encourage the patient and her family Allowing them to understand clearly
to verbalize their feelings the situation
Help them to develop effective coping Helps the SOs and mother cope with
strategies, referring them for the situation properly
counseling if necessary .
NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 400- 406
ABRUPTIO PLACENTA NURSING CARE PLAN
Nursing Diagnosis: Anxiety r/t maternal-fetal outcome due to the lack of knowledge about the effects of early placental separation
secondary Abruptio Placenta
Prepare the patient and family To help the SOs understand the critical
members for the possibility of an condition of the mother and have
emergency CS delivery, the delivery reassurances of the mother’s current
of a premature neonate and the condition
changes to expect in the postpartum
period To help the SOs and mother to prepare
physically and emotionally to the
offer emotional support and an honest situation
assessment of the situation
NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN
DOENGES, MARY FRANCES MOORHOUSE, ALICE C. MURR, PAGE 62 - 67
PLACENTA PREVIA NURSING CARE PLAN
Nursing Diagnosis: Fluid Volume Deficit r/t blood loss secondary to low Placental Implantation
Objective: Long Term: Monitor color, odor, consistency, Provide objective evidence of bleeding.
amount and type of bleeding; weigh Long Term:
Slightly pale pads
After 4 days of nursing
Cold , Clammy skin
interventions, the The patient
Low Blood Pressure Position mother on her left side. To improve placental perfusion.
patient will maintain shall have
Increased Heart rate
fluid volume at a maintained
Body weakness Assess hourly intake and output. Provides information about maternal
functional level AEB fluid volume
Fetal Heart Rate less and fetal physiologic compensation to
individually adequate at a functional
than normal blood loss.
urinary output and level AEB
Bleeding episodes
stable vital signs. individually
Decreased urine output Restrict vaginal examination. Prevents tearing of placenta if placenta
adequate
Abdomen soft/hard previa is the cause of bleeding.
urinary output
when palpated
and stable
Assess fetal heart tone. Assess whatever labor is present and
vital signs.
fetal status and external system avoids
cervical trauma.
Assess for changes in LOC: note for To detect signs of cerebral perfusion
complaints of thirst or apprehension
Monitor lab. Work as obtained: Hgb & Lab Work provides information about
Hct, Rh and type, cross match for 2 degree of blood loss; prepares for
units RBCs, urinalysis, etc. possible transfusion. Ultrasound
Scheduled for ultrasound as ordered. provides info about the cause
of bleeding
PLACENTA PREVIA NURSING CARE PLAN
Nursing Diagnosis: Ineffective tissue perfusion r/t decreased HgB concentration in blood & hypovolemia secondary to placenta
previa
Nursing Diagnosis: Acute Pain at the back related to increasing weight of gravid uterus.
Uneasy Instruct the client to verbalize pain in To be able to determine the type or
scale 1-10. level of care to be given.
DEPENDENT
Nursing Diagnosis: Impaired urinary elimination related to changes in usual voiding pattern.