ASSESSMENT

NURSING DIAGNOSIS
Deficient fluid volume related to excessive blood loss as evidenced by alteration in the vital signs and use of ten pads a day.

KNOWLEDGE BACKGROUND

PLANNING/GOAL

INTERVENTION

EVALUATION

Subjective data: I m 7 months pregnant yet I experience vaginal bleeding for almost 2 days and it s so red as verbalized by the pregnant women. Objective Data: v/s taken: BP: 90/60 RR: 35 PR: 130 >bright vaginal discharge noted > use of 10 pads a day noted > skin turgor (5 secs) >anxiety observed >Pale in appearance

. Abruptio placenta is After 8 hours of >Monitor Vital sign; blood premature separation of intervention the pressure, pulse rate, the normally implanted client will/would be: respirations, central venous placenta in the third pressure, intake and output, trimester. There are two Short-term and amount of vaginal types of abruption >to replace fluid loss bleeding. placenta conceal led and prevent further R: this will serve as a baseline hemorrhage and external blood loss. data and to prevent further hemorrhage. With complication. concealed hemorrhage, >to educate and the placenta separation provide >assess the gestational age of centrally and a large understanding the fetus, severity of amount of blood ids about the condition. abruption, associated accumulated under the complications and the status placenta. When an Long-term of the mother and the fetus. external hemorrhage is >To formulate R: this will aid in the present the separation is discharge planning formulation of a better along the placental and home care. nursing action/ interventions. margin and the blood flows under the > Reassure the patient of her membranes and through progress through labor, and the cervix. Women at keep her informed of the risk for developing fetus s condition. abruption placenta R:Because of the neonate s include those with prematurity, the mother may history of hypertension not receive an analgesic or previous abruption during labor and may placenta, abdominal experience intense pain trauma during pregnancy, anomaly of >If vaginal delivery is elected, the umbilical cord provide emotional support advanced maternal age, during labor. cigarette smoking and R: to enhance support system

After 8 hours of intervention the client: >fluid loss replaced as evidenced by vital signs stability at normal parameters, decreased used pads a day from 10 to 2 pads. >client demonstrated understanding and awareness as evidenced by smiling, decreased anxiety, less verbalization of concerns.

cocaine abuse. >advised client to rest R: to conserve energy and provide relaxation. >position client at sidelying position. R:to promote optimum placental perfusion. >Encourage the patient and her family to verbalize their feelings. Help them to develop effective coping strategies. Refer them for counseling, if necessary. R: to listen about their concerns and give therapeutic communication and to divert their attention somewhat lessens the thinking of problems >suggested client be on NPO status. R: in preparation for possible emergent caesarian. >weigh perineal pad before and after use. R:for accurate assessment of vaginal bleeding. >monitor fetal condition by daily non-stress test and kick counts.

R: to assess fetal condition >assess the status of the abdomen whether tender, soft or board-like. R: this is important in assessing the accumulation of blood in the abdomen. >mark the fundus and observed for an increase in fundal height R:indicating for concealed bleed. > formulate discharge planning and teach home healthcare guidelines for abruptio placentae R: to provide awareness and understanding about the disease and its occurrences. >Give the usual postpartum instructions for avoiding complications. Inform the patient that she is at much higher risk of developing abruptio placentae in subsequent Pregnancies. Instruct the patient on how to provide safe care of the infant. R: to provide knowledge during postpartum and to give self-awareness

Collaborative management: >provide oxygen therapy R: to oxygenate the mother and the fetus to prevent hypoxia. >blood typing and crossmatching recommended and R:done prior .for possible blood transfusion. >administer Ringers lactate R: to replace fluid loss >administered desired medication, ( bethametasone), tocolytic drugs R: for safety and fetal lung maturity. >coagulation studies advised as indicated and ordered. R: to prevent possible complication such as thrombophlebitis.