Abruptio Placenta Nursing Care Plan

Ineffective Tissue Perfusion ASSESSMENT Patient may manifest: FHR pattern Altered BP compared to baseline Altered PR Severe abdominal pain O2sat: 86% Board-like uterus Decrease urine output Edema Positive Homans sign Skin temperature changes Ineffective Tissue Perfusion related to excessive blood loss secondary to premature separation of the placenta One of the symptoms of premature separation of the placenta is uterine bleeding with a small amount to moderate of dark-red vaginal bleeding in 8085% cases. Bleeding may result to maternal hypervolemia and coagulopathy. Short Term: After 4 hours of nursing intervention, the patient will verbalize understanding of condition, therapy regimen, side effects of medication, and when to contact health care provider. Long Term: After 2 days of nursing intervention, patient will demonstrate life style changes/behavior that will improve circulation. 1. Assess patients vital signs, O2 saturation, and skin color. 2. Monitor for restlessness, anxiety, hunger and changes in LOC 1. To obtain baseline data Short term: Patient shall have verbalized understanding of condition, therapy regimen, side effects of medication, and when to contact health care provider. DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES INTERVENTION RATIONALE
EXPECTED OUTCOME

2. These conditions may indicate decrease cerebral perfusion 3. To obtain data about renal perfusion and function and the extent of blood loss. 4. To provide information regarding fetal distress and/or worsening of condition 5. To determine the severity of the placental abruptio and bleeding 6. To determine

3. Monitor accurately I&O

4. Monitor FHT continuously

Long Term: Patient shall have demonstrated life style changes/behaviors that will improve circulation.

5. Assess uterine irritability, abdominal pain and rigidity.

6. Assess skin color, temperature, moisture, turgor, capillary refill 7. Elevate extremity above the level of the heart

peripheral tissue perfusion like hypervolemia. 7. To promote circulation

8. Uterine pressure can cause pooling 8. Teach patient not to of venous blood in apply uterine lower extremities pressure 9. To immediately 9. Teach to report provide additional immediately signs interventions and symptoms of thrombosis: (1) pain in leg, groin (2) unilateral leg swelling (3) pale skin