Nursing Care Plan (NCP)

Nursing Diagnosis: Fluid Volume Deficit r/t massive vaginal hemorrhage due to secondary to complete placental separation

Cues Objective Nursing Intervention Rationale Evaluation

Subjective: STO: Continuous evaluate maternal and Alteration in vital signs can call for
fetal physiologic status, particularly: prompt actions.
The patient may After 30-60 minutes  Vital Signs
report: of administering  Bleeding
Thirst oxygen supplement  Electronic fetal and maternal
Weakness and performing monitoring tracings
Dizziness blood transfusion,  Signs of shock – rapid pulse,
the patient’s blood cold and moist skin, decrease in
components that blood pressure
were lost will be  Decreasing urine output
replaced and the
 Never perform a vaginal or
patient’s circulation
rectal examination or take any
of blood and oxygen
action that would stimulate
delivery/transport to
uterine activity.
the tissues will be
stabilized.
Objective: If the client is in active labor and
Asses the need for immediate
bleeding cannot be stopped with bed
delivery..
Decreased urine LTO: rest, emergency cesarean delivery
output; increased urine may be indicated
concentration After 1-2 hrs of
Decreased venous continuing oxygen
filling; decreased pulse supplementation, To prevent pressure on the vena
On admission, place the woman on
volume/pressure administering blood cava.
bed rest in a lateral position
Sudden weight loss transfusion, and
(except in third providing a calm
Insert a large gauge intravenous
spacing) and stimulant free for fluid replacement.
catheter into a large vein for fluid
Decreased BP; environment such
replacement.
increased pulse as limiting the
rate/body temperature visitation hours, the
Decreased patient will be able
Obtain a blood sample for fibrinogen
skin/tongue turgor; dry show improvements
level.
skin/mucous such as moist skin, To find out the extent of hemorrhage
membranes moist mucus for prompt intervention.
Change in mental membrane, normal
Monitor the FHR externally and
state skin turgor (<1-2 Allows prompt intervention if fetal
Elevated hematocrit sec), pinkish skin, measure maternal vital signs every 5 distress is detected.
Decreased blood and normal blood to 15 minutes.
pressure (<120/80) pressure within the
Dry skin range of Prepare for cesarean section the method of choice for the birth
Dry mucous 100/80mmHG-
membrane 130/90mmHg. Allows them to understand the
Decreased skin turgor Provide client and family teaching. situation
(>1-2 seconds)
Increased pulse rate Address emotional and psychosocial Calms client and helps her to take in
Increased blood needs. the stress.
clotting factors
increased body Maintain accurate I/O and weigh To evaluate effectiveness of
temperature (>36.7- daily. Measure urine specific gravity. resuscitation measures.
37.5*C) Monitor blood
confusion pressure and invasive hemodynamic
Pallor parameters as indicated (e.g., CVP,
PAP/PCWP)

Change position frequently. Bathe

infrequently, using mild to maintain skin integrity and prevent
cleanser/soap, and provide excessive dryness
optimal skin care with emollients caused by dehydration.

Assess and monitor vital signs;

BP,PR,RR, temp
Alterations in the vital signs may
indicate that there is something wrong
in the body systems.
Provide fluid replacement needs and
routes to be used. Prevents peaks in fluid level.

Administer IV fluids. Administer

blood products/ plasma expanders To replace the fluid lost in the body.
as indicated.

Control humidity and ambient air

temperature and perform TSB when Humidity and air temperature affects
there is fever. any changes in the body temperature
of the client.
Provide and perform oral care and
 eye care, and skin care. To prevent tissue injury from dryness.

Provide safety measures such as Protects the patient from any physical
raising the side rails and keeping injuries.
sharp things away from the patient,
that is, when the client is confused.

Provide and maintain a clean and

well ventilated room, and provide These promote comfort to the patient.
and maintain a calm and quiet
environment.

Administer antipyretics to reduce Fever further causes dryness and

fever as ordered by the physician. dehydration.

Administer oxygen supplement via

mask. Decrease in blood due to hemorrhage
means the decrease in oxygen supply
in the body. Administering oxygen via
mask provides more oxygen faster.

To prevent further complications to

Stop blood loss: administer the mother and to prevent fetal
anticoagulant drugs as ordered, and demise/ death.
prepare for surgical intervention or
immediate delivery as needed.

NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN DOENGES, MARY FRANCES MOORHOUSE, ALICE
C. MURR, PAGE 316- 319
 Nursing Care Plan (NCP)
Nursing Diagnosis: Impaired gas exchange: fetal r/t insufficient maternal-fetal oxygen transfer and supply secondary to premature separation of the placenta

Cues Objective Nursing Intervention Rationale Evaluation

Subjective: STO: Auscultate mother’s abdomen to hear To determine of there are any signs
the fetal heart tone. of life of the fetus inside the womb.
Within 15-30 minutes Assess and monitor fetal heart tone,
of providing oxygen beat and movement.
supplement to the To determine what appropriate
mother, thee fetus will Assess level of consciousness of the interventions should be given
be able to receive mother.
adequate oxygen To assess respiratory efficiency
from the impairment Evaluate pulse oxymetry to determine
of gas exchange and oxygenation.
allow transfer of To promote airway.
Objective: nutrients. Elevate head of bed or position the
mother appropriately
Decrease fetal heart LTO: Oxygen may transfer to the fetus,
tone Provide supplemental oxygenation at thus it provides oxygen and nutrients
Decrease fetal heart After 30-60 minutes of lowest concentration as indicated by to the fetus.
rate(70-120bpm) maintaining oxygen laboratory results.
Decrease fetal supplementation and
movements allowing the mother to Encourage or educate the mother to Helps limit oxygen needs or
have bed rest, the have adequate rest and limit activities consumption of the mother
Decrease maternal fetus will be able to to within client tolerance
oxygen saturation show improvements
(93%) such as having a fetal Promote/provide calm, restful, and
heart rate within the free stimulant environment. Promotes comfort to the mother
range of 120-160 bpm
and will show active Provide psychologic support such as
fetal movements. listening to questions or concerns. To establish rapport and trust

Administer medications as ordered by

the physician.
Assist with procedures as individually
indicated like blood transfusion.
Position mother in left lateral position
To treat underlying conditions
Improves respiratory function or
oxygen carrying capacity.
 Begin electronic fetal monitoring
Have equipment for emergency
cesarean delivery readily available
Prepare the patient and family
members for the possibility of an
emergency CS delivery, the delivery
of a premature neonate and the
changes to expect in the postpartum
period
offer emotional support and an
honest assessment of the situation
tactfully discuss the possibility of
neonatal death
encourage the patient and her family
to verbalize their feelings
Help them to develop effective coping
strategies, referring them for
counseling if necessary
Helps the SOs and mother cope with
the situation properly
NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN DOENGES, MARY FRANCES MOORHOUSE, ALICE
C. MURR, PAGE 322 - 327
To help in the circulation, and avoid
compressing the vena cava
to continuously assess FHR
The delivery method of choice is CS
To help the SOs understand the
critical condition of the mother and
have reassurances of the mother’s
current condition
To help the SOs and mother to
prepare physically and emotionally to
the situation
-tell the mother that the neonate’s
survival depends primarily on
gestational age, the amount of blood
lost, and associated hypertensive
disorders-assure her that frequent
monitoring and prompt management
greatly reduce the risk of death.
Allowing them to understand clearly
the situation
 Nursing Care Plan (NCP)
Nursing Diagnosis: Altered comfort: acute pain related to increase pressure in the abdomen and bleeding between the uterine wall due to massive accumulation of blood clots behind the
placenta secondary to premature separation of the placenta
Cues Objective Nursing Intervention Rationale Evaluation
Subjective: STO: Educate patient to have a bed rest. May relieve pain.
Allow patient to be in the left side-
patient reports a sharp After 45-60 minutes of lying position or any position that is
knife-like stabbing pain administering comfortable for her.
in her abdomen anticoagulant agents
and monitoring vital Administer tocolytic medications as
signs, the patient will ordered. Tocolytic agents reduce uterine
be able to report contractility/activity.
improvements such Administer anticoagulant agents as
as the decrease of ordered. To decrease/reduce blood clots.
pain in the abdomen
due to the reduction
of blood clots formed Measure abdominal girth. Increase in size that is more than
behind the placenta. normal may indicate that there is an
Objective: abnormal accumulation inside the
abdomen
Protective behavior LTO:
Grimace face Vital signs usually is altered acute
Crying After 4-6hrs of Monitor patient’s vital signs. pain
Irritable monitoring patient’s
Restless vital signs, assessing To help determine possibility of
diaphoresis pain scale, and Assess for referred pain, as underlying condition requiring
decrease BP providing comfort and appropriate. treatment.
(<110/70mmHG) safety measures
increase RR (25bpm) together with the May alleviate pain
increase PR (140bpm) administration of Encourage verbalizations of feelings
tocolytic drugs (as about the pain.
ordered by the To provide non-pharmocologic
doctor), the patient’s Provide/perform comfort measures treatment.
improvements such when necessary (back rub, change of
as the reduction of position). Provide quiet environment
pain will be and calm activities.
maintained.
Monitor fetal heart tone, beat, Vagueness/absence of fetal heart
movements. If vague and absent, tone, beat, and fetal movements may
prepare for surgery/delivery. indicate fetal hypoxia/death
Prepare blood products, IV fluids for
fluid replacement from bleeding and
blood clotting.
Position mother in left lateral position
Begin electronic fetal monitoring
Have equipment for emergency
cesarean delivery readily available
Prepare the patient and family
members for the possibility of an
emergency CS delivery, the delivery
of a premature neonate and the
changes to expect in the postpartum
period
offer emotional support and an
honest assessment of the situation
tactfully discuss the possibility of
neonatal death
encourage the patient and her family
to verbalize their feelings
Help them to develop effective coping
strategies, referring them for
To replace the blood being formed to
aclot and prevent replaced fluid loss
that would lead to tissue injury due to
dehydration.
To help in the circulation, and avoid
compressing the vena cava
to continuously assess FHR
The delivery method of choice is CS
To help the SOs understand the
critical condition of the mother and
have reassurances of the mother’s
current condition
To help the SOs and mother to
prepare physically and emotionally to
the situation
-tell the mother that the neonate’s
survival depends primarily on
gestational age, the amount of blood
lost, and associated hypertensive
disorders-assure her that frequent
monitoring and prompt management
greatly reduce the risk of death.
Allowing them to understand clearly
the situation
Helps the SOs and mother cope with
the situation properly
 counseling if necessary

Assess the patient’s extent of To monitor extent and condition of

bleeding and monitor fundal height q the bleeding for prompt intervention
30 mins.

(if the level of the fundus increases,

Draw line at the level of the fundus suspect abruptio placentae)
and check it every 30 mins
to determine the amount of blood
Count the number of pads that the loss
patient uses, weighing them as
necessary
To determine any changes that can
Monitor maternal blood pressure, alter the mother’s condition, and for
pulse rate, respirations, central prompt intervention
venous pressure, intake and output
and amount of vaginal bleeding q 10
– 15 mins

NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN DOENGES, MARY FRANCES MOORHOUSE, ALICE
C. MURR, PAGE 494 - 499
 Nursing Care Plan (NCP)
Nursing Diagnosis: risk for fetal injury r/t impaired maternal – fetal nutrition and oxygen transfer to the fetus secondary to premature placental separation.
Cues Objective Nursing Intervention Rationale Evaluation
Subjective: STO: Educate mother to have a complete bed Bed rest helps prevent further
Patient reports Within 20-40 rest. complications and helps limit
abdominal discomfort minutes of oxygen consumption.
(maternal). administering IV
fluids and oxygen Assess and monitor continuously the Alterations of the vital signs of the
Objective: supplement to the vital signs of the mother and the fetus. mother and fetus from the normal
Weak fetal heart rate mother, the fetus values may indicate that there is
and tone will be able to something wrong in the body of the
receive adequate mother.
Decrease fetal amount of oxygen Evaluate pulse oximetry of the mother
movement and nutrients for life to determine oxygen saturation in her To assess respiratory insufficiency.
support. body.
Little/no vaginal
bleeding (maternal) LTO: Provide/administer supplemental This provides adequate supply of
Within 1-4hrs of oxygen saturation at lowest oxygen to the blood of the mother
letting the mother concentration or as indicated by the while circulating, thus nutrients and
have complete bed laboratory results. oxygen will be transported to the
rest, providing fetus.
safety measures Administer IV fluids, as indicated.
and promoting a For nutritional support to the mother
clean and quiet and fetus and for fluid replacement,
environment, the if vaginal bleeding occurs.
fetus will be able to Provide safety measures (e.g. raise
receive continuous side rails and keeping off things that are To protect client from injuries and to
amount of oxygen sharp and edgy), and promoting a clean provide the patient comfort
necessary for the and quiet environment.
transportation of
nutrients. Position mother in left lateral position
To help in the circulation, and avoid
compressing the vena cava
Begin electronic fetal monitoring
to continuously assess FHR
Have equipment for emergency
cesarean delivery readily available
The delivery method of choice is CS
Prepare the patient and family
 members for the possibility of an
emergency CS delivery, the delivery of
a premature neonate and the changes
to expect in the postpartum period
offer emotional support and an honest
assessment of the situation
tactfully discuss the possibility of
neonatal death
encourage the patient and her family to
verbalize their feelings
Help them to develop effective coping
strategies, referring them for counseling
if necessary
NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN DOENGES, MARY FRANCES MOORHOUSE, ALICE
C. MURR, PAGE 400- 406
To help the SOs understand the
critical condition of the mother and
have reassurances of the mother’s
current condition
To help the SOs and mother to
prepare physically and emotionally
to the situation
Tell the mother that the neonate’s
survival depends primarily on
gestational age, the amount of
blood lost, and associated
hypertensive disorders-assure her
that frequent monitoring and prompt
management greatly reduce the risk
of death.
Allowing them to understand clearly
the situation
Helps the SOs and mother cope
with the situation properly
.
 Nursing Care Plan (NCP)
Nursing Diagnosis: Anxiety r/t maternal-fetal outcome due to the lack of knowledge about the effects of early placental separation secondary Abruptio Placenta
Cues Objective Nursing Intervention Rationale Evaluation
Subjective: STO: After 10- Give support emotionally by being Conveys acceptance and confidence
Patient verbalized, 15min of available and actively listening in ability to cope with situation.
“mabuhi pa ang ako assessing the
anak?” patient’s Ascertain client’s perception of what is To measure the level of
Decreased self perception and occurring and how this affects life. perception/consciousness of the
assurance giving emotional client.
support, client will Note degree of concentration, focus of
Objective: be able to calm attention. To know if patient knows the real
Crying down and think situation.
Pallor that she is not Measure vital signs/physiologic
Fatigue alone. responses to situation. To assess clients perception to the
Increase pulse rate situation.
(120-160bpm) LTO: After 30- Stay with client or make some
confused 60min of providing arrangements to have someone else be Sense of abandonment can
genuine there. exacerbate fear.
information about
the situation and Provide information truthfully in
allowing patient to verbal/written form. Speak in simple Facilitates understanding and
raise some sentences and concrete terms. retention to information.
questions and
answer it honestly, Provide opportunity to the patient to ask
the client will be some questions and nurses must answer
able to accept honestly. Enhances sense of trust and nurse-
slowly the situation client relationship.
and the outcome. Provide objective information when
available when available and allow client
to use it freely. Avoid arguing about
client’s perceptions of the situation. Limits conflicts when fear response
may impair rational thinking.
Encourage contact with a peer who has
successfully dealt with similar fearful
situations.
Provides a role model, and client is
Refer to supportive groups, community more likely to believe others who had
agencies/organizations, as indicated. similar experience.
Provides ongoing assistance for
Administer anti-anxiety medications, as individual needs.
ordered by physician
Provide quiet and calm environment.
Position mother in left lateral position
Begin electronic fetal monitoring
Have equipment for emergency
cesarean delivery readily available
Prepare the patient and family members
for the possibility of an emergency CS
delivery, the delivery of a premature
neonate and the changes to expect in
the postpartum period
offer emotional support and an honest
assessment of the situation
tactfully discuss the possibility of
neonatal death
encourage the patient and her family to
verbalize their feelings
Help them to develop effective coping
strategies, referring them for counseling
if necessary
It helps calm the patient.
Gives comfort to patient.
to continuously assess FHR
The delivery method of choice is CS
To help the SOs understand the
critical condition of the mother and
have reassurances of the mother’s
current condition
To help the SOs and mother to
prepare physically and emotionally to
the situation
To help the SOs and mother to
prepare physically and emotionally to
the situation
Tell the mother that the neonate’s
survival depends primarily on
gestational age, the amount of blood
lost, and associated hypertensive
disorders-assure her that frequent
monitoring and prompt management
greatly reduce the risk of death.
 Allowing them to understand clearly
the situation

Helps the SOs and mother cope with

the situation properly

NURSING DIAGNOSIS MANUAL, 2ND EDITION: PLANNING, INDIVIDUALIZING AND DOCUMENTING CLIENT CARE, BY MARILYNN DOENGES, MARY FRANCES MOORHOUSE, ALICE
C. MURR, PAGE 62 - 67