Nursing Care Plan (NCP)

Assessment Patient manifest: FHR pattern Altered BP compared to baseline Altered PR Severe abdominal pain !sat: "#$ Board%li&e uterus Decrease urine output 'dema Positive Homan(s sign S&in temperature c)anges

Nursing Diagnosis acute pain related to increase pressure in t)e abdomen and bleeding bet*een t)e uterine *all due to massive accumulation of blood clots be)ind t)e placenta secondar+ to premature separation of t)e placenta

Goals S, : After -.%#/ minutes of administering anticoagulant agents and monitoring vital signs0 t)e patient *ill be able to report improvements suc) as t)e decrease of pain in t)e abdomen due to t)e reduction of blood clots formed be)ind t)e placenta1 2, : After -%#)rs of monitoring patient(s vital signs0 assessing pain scale0 and providing comfort and safet+ measures toget)er *it) t)e administration of tocol+tic drugs 3as ordered b+ t)e doctor40 t)e patient(s improvements suc) as t)e reduction of pain *ill be maintained1

Nursing Intervention 51 'ducate patient to )ave a bed rest1 Allo* patient to be in t)e left side%l+ing position or an+ position t)at is comfortable for )er1 !1 Administer tocol+tic medications as ordered1 61 Administer anticoagulant agents as ordered1 -1 7easure abdominal girt)1

Rationale 51 7a+ relieve pain1

!1 ,ocol+tic agents reduce uterine contractilit+:activit+1 61 ,o decrease:reduce blood clots1 -1 Increase in si9e t)at is more t)an normal ma+ indicate t)at t)ere is an abnormal accumulation inside t)e abdomen .1 ;ital signs usuall+ is altered acute pain

.1 7onitor patient(s vital signs1 #1 Assess for referred pain0 as appropriate1 81 'ncourage verbali9ations of feelings about t)e pain1 "1 Provide:perform comfort measures *)en necessar+

#1 ,o )elp determine possibilit+ of underl+ing condition re<uiring treatment1 81 7a+ alleviate pain "1 ,o provide non%p)armocologic treatment1

3bac& rub0 c)ange of position41 Provide <uiet environment and calm activities1 =1 7onitor fetal )eart tone0 beat0 movements1 If vague and absent0 prepare for surger+:deliver+1 5/1 Prepare blood products0 I; fluids for fluid replacement from bleeding and blood clotting1

=1 ;agueness:absence of fetal )eart tone0 beat0 and fetal movements ma+ indicate fetal )+po?ia:deat) 5/1 ,o replace t)e blood being formed to aclot and prevent replaced fluid loss t)at *ould lead to tissue in@ur+ due to de)+dration1 551 ,o )elp in t)e circulation0 and avoid compressing t)e vena cava 5!1 to continuousl+ assess FHR

551 Position mot)er in left lateral position 5!1 Begin electronic fetal monitoring 561 Have e<uipment for emergenc+ cesarean deliver+ readil+ available 5-1 Prepare t)e patient and famil+ members for t)e possibilit+ of an emergenc+ >S deliver+0 t)e deliver+ of a premature neonate and t)e c)anges to e?pect in t)e postpartum period

561 ,)e deliver+ met)od of c)oice is >S 5-1 ,o )elp t)e S s understand t)e critical condition of t)e mot)er and )ave reassurances of t)e mot)er(s current condition

5.1 ,o )elp t)e S s and mot)er to prepare p)+sicall+ and emotionall+ to t)e situation 5#1 %tell t)e mot)er t)at t)e neonate(s survival depends primaril+ on gestational age0 t)e

5.1 offer emotional support and an )onest assessment of t)e situation 5#1 tactfull+ discuss t)e possibilit+ of neonatal deat)

amount of blood lost0 and associated )+pertensive disorders%assure )er t)at fre<uent monitoring and prompt management greatl+ reduce t)e ris& of deat)1 581 Allo*ing t)em to understand clearl+ t)e situation

581 encourage t)e patient and )er famil+ to verbali9e t)eir feelings 5"1 Help t)em to develop effective coping strategies0 referring t)em for counseling if necessar+ 5=1 Assess t)e patient(s e?tent of bleeding and monitor fundal )eig)t < 6/ mins1 !/1 Dra* line at t)e level of t)e fundus and c)ec& it ever+ 6/ mins !51 >ount t)e number of pads t)at t)e patient uses0 *eig)ing t)em as necessar+ !!1 7onitor maternal blood pressure0 pulse rate0 respirations0 central venous pressure0 inta&e and output

5"1 Helps t)e S s and mot)er cope *it) t)e situation properl+ 5=1 ,o monitor e?tent and condition of t)e bleeding for prompt intervention !/1 3if t)e level of t)e fundus increases0 suspect abruptio placentae4 !51 to determine t)e amount of blood loss !!1 ,o determine an+ c)anges t)at can alter t)e mot)er(s condition0 and for prompt intervention

and amount of vaginal bleeding < 5/ A 5. mins