ABRUPTIO PLACENTA

Ineffective Tissue Perfusion related to excessive blood loss as evidenced by

 Loss of blood
 FHR pattern
 Altered BP compared to baseline
 Altered PR Severe abdominal pain and rigidity
 Pallor
 Changes in LOC
 Decrease urine output
 Edema
 Delay in wound healing
 Positive Homan’s sign
 Skin temperature changes

Desired outcome:

Nursing Interventions Rationale

Assess patient’s vital signs, O2 saturation, and skin

For baseline data.
color.

Monitor for restlessness, anxiety, hunger and These conditions may indicate
changes in LOC decreased cerebral perfusion

To obtain data about renal perfusion

Monitor accurately I&O and function and the extent of blood
loss.

To provide information regarding fetal

Monitor FHT continuously
distress and/or worsening of condition

To determine the severity of the

Assess uterine irritability, abdominal painand rigidity.
placental abruptio and bleeding
Assess skin color, temperature, moisture, turgor, To determine peripheral tissue
capillary refill perfusionlike hypervolemia.

Elevate extremity above the level of the heart Helps promote circulation.

Uterine pressure can cause pooling of

Teach patient not to apply uterine pressure
venous blood in lower extremities

Instruct patient and/or SO to report immediately

To immediately provide additional
signs and symptoms of thrombosis: (1) pain in leg,
interventions
groin (2) unilateral leg swelling (3) pale skin

Risk for Shock

Related to:

 Significant blood loss of about 10% of the blood volume

 Separation of the placenta
 External or internal bleeding

Possibly evidenced by:

 Vaginal bleeding
 Couvelaire uterus or a tense and rigid uterus
 Increased pulse rate
 Decreased blood pressure
 Increased respiratory rate
 Decreased central venous pressure
 Decreased urine output
 Decreasing level of consciousness
 Cold, clammy skin
  Fetal bradycardia

Desired outcomes:

 Patient will display hemodynamic stability.

 Patient will regain vital signs within the normal range.
 Patient will be able to verbalize understanding of disease process, risk
factors, and treatment plan.
 Patient will display a normal central venous pressure.
 Patient’s skin is warm and dry.
 Fetal heart rate is within normal range.
 Patient will exhibit an adequate amount of urine output with normal
specific gravity.
 Patient will display the usual level of mentation.

Nursing Interventions Rationale

The condition may deplete the body’s

Assess for history or presence of
circulating blood volume and the ability to
conditions leading to hypovolemic shock.
maintain organ perfusion and function.

Monitor for persistent or heavy fluid or The amount of fluid or blood loss must be
blood loss. noted to determine the extent of shock.

Assess vital signs and tissue and organ

For changes associated with shock states
perfusion.

To identify potential sources of shock and

Review laboratory data.
degree of organ involvement.

Collaborate in prompt treatment of

underlying conditions and prepare for or To maximize systemic circulation and tissue
assist with medical and surgical and organ perfusion.
interventions.

Administer oxygen by appropriate route. To maximize oxygenation of tissues.

 Administer blood or blood products as To rapidly restore or sustain circulating
indicated. volume and electrolyte balance.

Assesses whether labor is present and fetal

Monitor uterine contractions and fetal
status; external system avoids cervical
heart rate by external monitor.
trauma.

Withhold oral fluid. Anticipates need for emergency surgery.

Measure intake and output. Enables assessment of renal function.

Measure maternal blood loss by weighing

Provides objective evidence of
perineal pads and save any tissue that
amount bleeding.
has passed.

Maintain a positive attitude about fetal

Supports mother-child bonding.
outcome.

Provide emotional support to the woman Assists problem solving which is lessened
and her support person. by poor self-esteem.

Acute Pain

Related to:

 Sudden separation of placenta from the uterine wall

 Pain accompanying labor contractions during initial separation

Possibly evidenced by:

 Sharp, stabbing pain high in the uterine fundus

 Uterine tenderness

Desired outcomes:

 Patient will report relief or control of pain.

  Patient will follow prescribed pharmacological regimen.
 Patient will verbalize non pharmacological methods that provide relief.
 Patient will demonstrate use of relaxation skills and diversional
activities as indicated.

Nursing Interventions Rationale

To help determine the possibility of

Assess for referred pain as appropriate. underlying condition or organ dysfunction
requiring treatment.

Individuals with external locus of control

Note client’s locus of control. may take little or no responsibility for pain
management.

Note and investigate changes from To rule out worsening of underlying

previous reports of pain. condition or development of complications.

Acknowledge the client’s description of

Pain is a subjective experience and cannot
pain and convey acceptance of client’s
be felt by others.
response to pain.

Monitor skin color and temperature and

These are usually altered in acute pain.
vital signs.

Note when pain occurs. To medicate as appropriate.

Provide comfort measures, quiet To promote non pharmacological pain

environment, and calm activities. management.

Administer analgesics as indicated. To maintain an acceptable level of pain.

Encourage adequate rest periods. To prevent fatigue.