NURSING CARE PLAN
ASSESSMENT
Subjective: “Bigla na lang akong dinugo (I’m bleeding)” as verbalized by the patient. Objective: • Changes in fetal heart rate or fetal activity. Release of meconium. V/S taken as follows: T: 36.9 P: 96 R: 22 Bp: 100/80
DIAGNOSIS
Impaired fetal gas exchange related to altered blood flow and decreased surface area of gas exchange at site of placental detachment.
INFERENCE Placenta previa is the development of placenta in the lower uterine segment, partially or completely covering the internal cervical os. The cause is unknown, but a possible theory states that the embryo will implant in the lower uterine segment if the deciduas in the uterine fundus is not favorable. Complications are immediate hemorrhage, shock, and maternal death; fetal mortality; and post partum
PLANNING
After 8 hours of nursing interventions, the patient will verbalize understanding of causative factors and appropriate interventions.
INTERVENTION
Independent: • Assess vital signs • (pulse, respirations, and blood pressure every 15 minutes). • Maintain bed rest • or chair rest when indicated. Provide frequent rest periods and uninterrupted night time sleep. • •
RATIONALE
.Provides baseline data on maternal blood loss. •
EVALUATION
After 8 hours of nursing interventions, the patient was able to verbalize understanding of causative factors and appropriate interventions.
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Monitor amount and type of bleeding. Position mother on her left side. Restrict vaginal examination.
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Monitor uterine contractions and fetal heart rate by external monitor.
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Maintain positive attitude toward about fetal
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Systemic rest is mandatory and important throughout all phases of disease to reduce fatigue, and improve strength. Provide objective evidence of bleeding. To promote placental perfusion. Prevents tearing of placenta if placenta previa is the cause of bleeding. Assess whether labor is present and fetal status and external system avoids cervical trauma. Supports mother and child bonding.
hemorrhage.
outcome. Collaborative: • Administer oxygen as indicated. •
Provides adequate fetal oxygenation despite of lowered maternal circulating volume.