Nursing Care Plans
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
> Bleeding Episodes (amount, duration)
> Facial Grimace due of Pain
> Complaint of pain
Abdomen soft/hard when palpated
> Manifest Body Weakness
> Low BP
Fetal HR >120-160 bpm
> Decreased Urine Out
> Increased Urine Concentration
> Pale, Cool Skin
>Increased Capillary Refill
After 4 hours of NI, the pt will verbalize understanding of causative factors.
After 4 days of NI, the pt will maintain fluid volume at a functional level AEB individually adequate urinary output and stable vital signs.
2.Monitor Vital Signs
3.Assess color, odor, consistency and amount of vaginal bleeding; weigh pads
4.Assess hourly intake and output.
5. Assess baseline data and note changes. Monitor FHR.
6. Assess abdomen for tenderness or rigidity- if present, measure abdomen at umbilicus (specify time interval)
7. Assess SaO2, skin color, temp, moisture, turgor, capillary refill (specify frequency)
8. Assess for changes in LOC: note for complaints of thirst or apprehension
9. Provide supplemental O2 as ordered via face mask or nasal cannula @ 10-12 L/min.
10.Initiate IV fluids as ordered (specify fluid type and rate).
11. Position Pt. in supine with hips elevated if ordered or left lateral position.
12.Monitor lab. Work as obtained: Hgb & Hct, Rh and type, cross match for 2 units RBCs, urinalysis, etc. Scheduled for ultrasound as ordered.
|1. To gain patient’s trust
2. To obtain baseline data
3. Provides information about active bleeding versus old blood, tissue loss and degree of blood loss
4. Provides information about maternal and fetal physiologic compensation to blood loss
5. Assessment provides information about possible infection, placenta previa or abruption. Warm, moist, bloody environment is ideal for growth of microorganisms.
6. Detecting increased in measurement of abdominal girth suggests active abruption
7. Assessment provides information about blood vol., O2 saturation and peripheral perfusion
8. To detect signs of cerebral perfusion
9. Intervention increases available O2 to saturate decreased hemoglobin
10. For replacement of fluid vol. loss
11. Position decreases pressure on placenta and cervical os. Left lateral position improves placental perfusion
12. Lab Work provides information about degree of blood loss; prepares for possible transfusion. Ultrasound provides info about the cause of bleeding
The pt shall have verbalized understanding of causative factors.
The pt shall have maintained fluid volume at a functional level AEB individually adequate urinary output and stable vital signs.
Decreased Cardiac Output
Placenta Previa is the development of placenta in the lower uterine segment partially or completely covering the internal cervical os. Placenta Previa causes bleeding. Due to large amounts of blood lost, the heart tries to pump faster in order to compensate for blood loss. As a result, the heart pumps faster with lesser blood pumped.
NDx: Decreased cardiac output r/t altered contractility
> prolonged capillary refill
> cold clammy skin
> variations in BP readings
After 4 hours of NI, the pt will participate in activities that reduce the workload of the heart.
After 4 days of NI, the pt will manifest hemodynamic stability.
The pt shall have participated in activities that reduce the workload of the heart.
The pt shall have manifested hemodynamic stability.
Ineffective Tissue Perfusion
Placenta Previa causes painless and continuous bleeding. With bleeding, there is decreased Hemoglobin. Hemoglobin carries oxygen to different parts of the body. If there is decreased hemoglobin there is a failure to nourish the tissues at the capillary level.
NDx: Ineffective tissue perfusion r/t decreased HgB concentration in blood & hypovolemia Secondary to placenta previa.
> Manifest Body Weakness
> Capillary refill more than 3 sec
After 4 hours of NI, the pt will demonstrate behaviors to improve circulation.
After 4 days of NI, the pt will demonstrate increased perfusion as individually appropriate
|1. Establish Rapport
2. Monitor Vital Signs
3. Assess patient condition
4. Note customary baseline data (usual BP, weight, lab values)
5. Determine presence of dysrhythmias
6. Perform blanch test
7.Check for Homan’s Sign
8.Encourage quiet & restful environment
10.Encourage use of relaxation techniques
|1.To gain patient’s trust
2.To obtain baseline data
3.To assess contributing factors
4. For comparison with current findings
5.To identify alterations from normal
6.To identify / determine adequate perfusion
7.To determine presence of thrombus formation
8.To lessen O2 demand
9.To promote circulation
10. To decrease tension level
|Short Term:The pt shall have demonstrated behaviors to improve circulation.
The pt shall have an increased perfusion as individually appropriate.