NURSING CARE PLAN
ASSESSMENT
Subjective: “Bigla na lang sumakit ng matindi ang tiyan ko , kahit 22 linggo palang ang ipinagbubuntis ko” (I’m 22 weeks
pregnant and I feel a sharp pain in my abdomen) as
DIAGNOSIS
Acute pain related to collection of blood between uterine wall and placenta.
INFERENCE
Abruptio placenta is premature separation of the normally implanted placenta in the third trimester. There are two types of abruption placentae; concealed hemorrhage and external hemorrhage. With a concealed hemorrhage, the placenta separation centrally, and a large amount of blood is accumulated under the placenta. When an external hemorrhage is present, the separation is along the placental margin, and blood flows under the
PLANNING
After 8 hours of nursing interventions, the patient will demonstrate use of relaxation skills, other methods to promote comfort.
INTERVENTION
Independent: • Monitor amount of bleeding by weighing all pads. • Investigate pain reports, noting location, duration, intensity (0-10 scale), and characteristics (dull, sharp, constant). • Monitor maternal vital signs and fetal heart rate through continuous monitoring. • Measure and record fundal height. •
RATIONALE
To measure the amount of blood loss. Changes in location or intensity are not uncommon but may reflect developing complications. Early recognition of possible adverse effects allows for prompt intervention. Fundal height may increase with concealed bleeding. To enhance placental perfusion.
EVALUATION
After 8 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills, other methods to promote comfort.
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verbalized by the patient. Objective: • • • • Abdominal guarding. Muscle tension. Irritability. V/S taken as follows: T: 37.3 P: 95 R: 22 Bp: 100/70
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Position mother in the left lateral position, with the head of the bed elevated. Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization
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Promotes relaxation and may enhance patient’s coping abilities by refocusing
membranes and through cervix. Women at risk for developing abruption placentae include those with history of hypertension or previous abruption placenta, abdominal trauma during pregnancy, anomaly of the umbilical cord, uterine fibroids, advanced maternal age, cigarette smoking, and cocaine abuse.
exercises. Provide diversional activities. Collaborative: • Administer oxygen as indicated. •
attention.
To supply adequate oxygen to the fetus and mother and prevents further complication.