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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.
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