3 Placenta Previa Nursing Care Plans

Placenta praevia (placenta previa AE) is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum hemorrhage (vaginal bleeding). It affects approximately 0.5% of all labors.

. Deficient Fluid Volume Fluid volume deficit is a state in which an individual is experiencing decreased intravascular, interstitial and/or intracellular fluid. Active Blood Loss or Hemorrhage due to disrupted placental implantation during pregnancy may manifest signs and symptoms of fluid vol. deficient that may later lead to hypovolemic shock and cause maternal and fetal death. NDx: Deficient Fluid Volume r/t Active Blood Loss Secondary to Disrupted Placental Implantation

Assessment SO->

Planning

Nursing Interventions

Rationale

Expected Outcome Term:The have

Short Term:After 4 1. Bleeding hours of NI, the pt Rapport2. verbalize Vital

Establish 1.

To gain patients Short To obtain pt data3.

Monitor trust2. Signs3. baseline

shall

Episodes (amount, will

verbalized

duration) > Facial

understanding of Assess color, odor, Provides information understanding of Grimace causative factors.Long consistency and about active bleeding causative old blood, factors.Long

due of Pain

amount of vaginal versus

> Complaint of pain Term:After 4 days bleeding; Abdomen soft/hard of NI, the pt will pads4. when palpated > Manifest maintain Body volume functional AEB at

weigh tissue loss and degree Term:The pt shall Assess of blood loss4. have maintained

fluid hourly intake and Provides information fluid volume at a a output. level 5. about maternal and functional level

Weakness > Low BP Increased HR Decreased RR

Assess baseline fetal and

physiologic AEB individually to adequate urinary output and stable Assessment vital signs.

individually data

note compensation Monitor blood loss 5.

adequate urinary changes. output and stable FHR. 6. for

Fetal HR >120-160 vital signs. bpm > Decreased Urine Out > Increased Urine Concentration > Pale, Cool Skin >Increased Capillary Refill

Assess abdomen provides information tenderness or about possible placenta

rigidity- if present, infection,

measure abdomen at previa or abruption. umbilicus time interval) 7. skin Assess color, (specify Warm, moist, bloody environment is ideal SaO2, for growth of

temp, microorganisms. turgor, 6. refill increased measurement Detecting in of girth active

moisture, capillary

(specify frequency) 8. Assess

for abdominal

changes in LOC: note suggests for thirst apprehension 9. complaints of abruption or 7.

Assessment

provides information Provide about blood vol., O2 and

supplemental O2 as saturation ordered

via peripheral perfusion To detect signs of

facemask or nasal 8. cannula @

10-12 cerebral perfusion

L/min.

9.

Intervention

10. Initiate IV fluids increases available O2 as ordered (specify to saturate decreased fluid type and rate). hemoglobin 11. Position Pt. in 10. with For replacement

supine

hips of fluid vol. loss Position

elevated if ordered 11. or left

lateral decreases pressure on placenta and cervical lab. os. Left lateral improves

position. 12. Monitor

Work as obtained: position

Hgb & Hct, Rh and placental perfusion type, cross match for 12. 2 units Lab. Work

RBCs, provides information etc. about degree of blood for loss; prepares for

urinalysis, Scheduled ultrasound ordered.

as possible

transfusion.

Ultra sound provides info about the cause bleeding