placenta-previa-nursing-care-plans

Definition

Placenta praevia is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. 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

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

AssessmentPlanningNursing
Inter­ventions
RationaleExpected Outcome
S-O-

>  Bleeding Episodes (amount, duration)

> Facial Grimace due of Pain

> Complaint of pain

Abdomen soft/hard when palpated

> Manifest Body Weakness

> Low BP

Increased HR

Decreased RR

Fetal HR >120-160 bpm

> Decreased Urine Out

> Increased Urine Concentration

> Pale, Cool Skin

>Increased Capillary Refill

Short Term:

After 4 hours of NI, the pt will verbalize understanding of causative factors.

Long Term:

After 4 days of NI, the pt will maintain fluid volume at a functional level AEB individually adequate urinary output and stable vital signs.

1.Establish Rapport

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

Short Term:

The pt shall have verbalized understanding of causative factors.

Long Term:

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

AssessmentPlanningNursing

Inter­ventions

RationaleExpected Outcome
S->  dysrhythmias

> prolonged capillary refill

> cold clammy skin

> Dyspnea

> restlessness

> variations in BP readings

Short Term:

After 4 hours of NI, the pt will participate in activities that reduce the workload of the heart.

Long Term:

After 4 days of NI, the pt will manifest hemodynamic stability.

  1. Establish Rapport
  2. Monitor Vital Signs
  3. History taking
  4. Assess patient condition
  5. Review lab data
  6. Monitor BP & Pulse frequently
  7. Provide information on test procedures
  8. Provide adequate rest & Reposition client
  9. Encourage relaxation techniques
  10. Elevate HOB
  11. Encourage use of relaxation techniques
  1. To gain patient’s trust
  2. To obtain baseline data
  3. To determine contributing factors
  4. To assess contributing factors
  5. For comparison with current normal values
  6. To note response to activity
  7. To gin pt’s participation
  8. To promote venous return
  9. To alleviate stress & anxiety
  10. To promote circulation
  11. To decrease tension level
Short Term:

The pt shall have participated in activities that reduce the workload of the heart.

Long Term:

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.

AssessmentPlanningNursing
Inter­ventions
RationaleExpected Outcome
S-O-

>  Restlessness

> Confusion

> Irritability

> Manifest Body Weakness

> Capillary refill more than 3 sec

> Oliguria

Short Term:

After 4 hours of NI, the pt will demonstrate behaviors to improve circulation.

Long Term:

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

9.Elevate HOB

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.

Long Term:

The pt shall have an increased perfusion as individually appropriate.