SHARE

Placenta previa is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. Placenta previa is a life-threatening maternal bleeding typically necessitates termination of the pregnancy. Maternal prognosis is good if hemorrhage can be controlled; fetal prognosis depends on the gestational age and amount of blood lost. Anemia may be managed by blood transfusion to permit the pregnancy to continue in utero. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum hemorrhage (vaginal bleeding). It affects approximately 0.5% of all labors.

Nursing Care Plans

Treatment of placenta previa is design to assess, control, and restore blood loss, and to deliver a viable infant. Immediate therapy includes starting an IV line using a large bore catheter. Here are 3 placenta previa nursing care plans.

1. 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.

Assessment

Patient may manifest: 

  • Bleeding episodes (amount, duration)
  • Abdomen soft/hard when palpated
  • Manifests body weakness
  • Low blood pressure
  • Increased heart rate
  • Decreased respiratory rate
  • Fetal heart rate less than normal (120-160 bpm)
  • Decreased urine output
  • Increased urine concentration
  • Pale, cold, clammy skin

Nursing Diagnosis

  • Deficient Fluid Volume r/t Active Blood Loss Secondary to Disrupted Placental Implantation

Planning

  • Patient will maintain fluid volume at a functional level possibly evidenced by adequate urinary output and stable vital signs.
Nursing Interventions Rationale
Establish Rapport To gain patient’s trust
Monitor Vital Signs To obtain baseline data
Assess color, odor, consistency and amount of vaginal bleeding; weigh pads Provides information about active bleeding versus old blood, tissue loss and degree of blood loss
Assess hourly intake and output. Provides information about maternal and fetal physiologic compensation to blood loss
Assess baseline data and note changes. Monitor FHR. Assessment provides information about possible infection, placenta previa or abruption. Warm, moist, bloody environment is ideal for growth of microorganisms.
Assess abdomen for tenderness or rigidity- if present, measure abdomen at umbilicus (specify time interval) Detecting increased in measurement of abdominal girth suggests active abruption
Assess SaO2, skin color, temp, moisture, turgor, capillary refill (specify frequency) Assessment provides information about blood vol., O2 saturation and peripheral perfusion
Assess for changes in LOC: note for complaints of thirst or apprehension To detect signs of cerebral perfusion
Provide supplemental O2 as ordered via face mask or nasal cannula @ 10-12 L/min. Intervention increases available O2 to saturate decreased hemoglobin
Initiate IV fluids as ordered (specify fluid type and rate). For replacement of fluid vol. loss
Position Pt. in supine with hips elevated if ordered or left lateral position. Position decreases pressure on placenta and cervical os. Left lateral position improves placental perfusion
Monitor lab. Work as obtained: Hgb & Hct, Rh and type, cross match for 2 units RBCs, urinalysis, etc. Scheduled for ultrasound as ordered. Lab Work provides information about degree of blood loss; prepares for possible transfusion. Ultrasound provides info about the cause of bleeding

2. 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.

Assessment

  • dysrhythmias
  • prolonged capillary refill
  • cold clammy skin
  • Dyspnea
  • restlessness
  • variations in BP reading

Nursing Diagnosis

  • Decreased cardiac output r/t altered contractility

Planning

  • Patient will participate and demonstrate activities that reduce the workload of the heart.
  • Patient will manifest hemodynamic stability.
Nursing Interventions Rationale
Establish Rapport To gain patient’s trust
Monitor Vital Signs To obtain baseline data
History taking To determine contributing factors
Assess patient condition To assess contributing factors
Review lab data For comparison with current normal values
Monitor BP & Pulse frequently To note response to activity
Provide information on test procedures To gin pt’s participation
Provide adequate rest & Reposition client To promote venous return
Encourage relaxation techniques To alleviate stress & anxiety
Elevate HOB To promote circulation
Encourage use of relaxation techniques To decrease tension level

3. 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.

Assessment

Patient may manifest

  • Restlessness
  • Confusion
  • Irritability
  • Manifest Body Weakness
  • Capillary refill more than 3 sec
  • Oliguria

Nursing Diagnosis

  • Ineffective tissue perfusion r/t decreased HgB concentration in blood & hypovolemia

Planning

  • Patient will demonstrate behaviors to improve circulation.
  • Patient will demonstrate increased perfusion as individually appropriate.
Nursing Interventions Rationale
Establish Rapport To gain patient’s trust
Monitor Vital Signs To obtain baseline data
Assess patient condition To assess contributing factors
Note customary baseline data (usual BP, weight, lab values) For comparison with current findings
Determine presence of dysrhythmias To identify alterations from normal
Perform blanch test To identify and determine adequate perfusion
Check for Homan’s Sign To determine presence of thrombus formation
Encourage quiet & restful environment To lessen O2 demand
Elevate HOB To promote circulation
Encourage use of relaxation techniques To decrease tension level

Other Possible Nursing Care Plans

  • Risk for Deficient Fluid Volume: risk factors may include excessive vascular losses
  • Impaired fetal Gas Exchange: may be related to altered blood flow, altered O2-carrying capacity of blood from maternal anemia, and decreased surface area of gas exchange at site of placental attachment, possible evidenced by changes in fetal heart rate/activity and release of meconium.
  • Fear may be related to threat of death to self or fetus, possibly evidenced by verbalization of specific concerns, increased tension, sympathetic stimulation.
  • Risk for Deficient Diversional Activity: risk factors may include imposed activity restrictions or bed rest.

See Also

NO COMMENTS

Comments are closed.