8/6/2019 Nursing Care Plan Abrubtio Placenta

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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:Bigla na lang

sumakit ngmatindi ang tiyanko , kahit 22linggo palangangipinagbubuntisko (Im 22 weeks

pregnant and I feel asharp pain in my abdomen) asverbalized by thepatient.

Objective: Abdominalguarding. Muscletension. Irritability.

Acute painrelated

to collection of blood betweenuterine wall andplacenta.

Abruptioplacenta

is prematureseparation of thenormallyimplantedplacenta in thethird trimester.There are twotypes of abruptionplacentae;concealed

hemorrhage andexternalhemorrhage.Witha concealedhemorrhage, theplacentaseparationcentrally, and alarge amount of blood is

accumulatedunder theplacenta. Whenan externalhemorrhage ispresent, theseparation isalong the

After 8 hours of nursing

interventions,thepatient willdemonstrateuseof relaxationskills,other methodstopromote comfort

Independent: Monitor amount

of bleeding byweighing allpads. Investigate painreports, notinglocation,duration,intensity (0-10scale), andcharacteristics(dull, sharp,

constant). Monitor maternalvital signs andfetal heart ratethroughcontinuousmonitoring. Measure andrecord fundalheight. Position mother in the left lateralposition, with thehead of the bedelevated. Provide comfortmeasure likeback rubs, deep

To measurethe amount of

blood loss. Changes inlocation or intensity arenotuncommonbut mayreflectdevelopingcomplications. Earlyrecognition of possibleadverseeffects allowsfor promptintervention. Fundal heightmay increasewithconcealedbleeding. To enhanceplacentalperfusion. Promotesrelaxation andmay enhancepatientscoping

After 8 hours of nursing

interventions,thepatient was abletodemonstrate useof relaxation skills,other methods topromote comfort

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placentalmargin,and blood flows

under themembranes andthrough cervix.Women at riskfor developingabruptionplacentaeincludethose withhistory

of hypertensionor previousabruptionplacenta,abdominaltraumaduringpregnancy,anomaly of theumbilical cord,

uterine fibroids,advancedmaternal age,cigarettesmoking, andcocaine abuse.

breathing.Instruct inrelaxation or

visualizationexercises.Providediversionalactivities.

Collaborative: Administer oxygen asindicated.

abilities byrefocusingattention.

To supplyadequateoxygen to thefetus andmother andpreventsfurther complication.