7 Prenatal Hemorrhage Nursing Care Plans

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FT -Prenatal Hemorrhage Nursing Care Plans

Prenatal hemorrhage happens due to certain physiological problems in the early or late stages of pregnancy, each with its own signs and symptoms, which aids in determining a differential diagnosis and in formulating a care plan. This nursing care plan focuses on managing hemorrhage during the prenatal period. Specific interventions are identified to address each physiological problem as indicated.

Nursing Care Plans

Nurse care planning for a client with prenatal hemorrhage include assess maternal/fetal condition, maintain circulatory fluid volume, assist with efforts to nurture the pregnancy, if possible, avoid complications, provide emotional support to the client/couple, and provide knowledge on short- and long-term complications of the hemorrhage.

Here are seven (7) nursing care plans (NCP) and nursing diagnosis for prenatal hemorrhage:

Ineffective [Uteroplacental] Tissue Perfusion

Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.

May be related to

Possibly evidenced by

Desired Outcomes

  • Client will display improved tissue perfusion, as evidenced by fetal heart rate and activity within normal limit and reactive non-stress test.
Nursing InterventionsRationale
Assess maternal physiological circulatory status and blood volume.An abnormal bleeding episode may lead to complications in pregnancy such as uteroplacental hypovolemia or hypoxia.
Auscultate and report FHR; note bradycardia or tachycardia. Note change in hypoactivity or hyperactivity.Assesses degree of fetal hypoxia. Initial response of a fetus to decreased oxygenation is tachycardia and increased movements. A further deficit will result in bradycardia and decreased activity.
Note expected date of birth (EDB) and fundal height.Provides an estimate for identifying fetal viability.
Monitor and record maternal blood loss and uterine contractions.Excess maternal blood loss compromises placental perfusion. If uterine contractions are accompanied by cervical dilatation, bedrest and medications may not be effective in maintaining the pregnancy.
Institute strict bed rest in lateral position.Relieves pressure on the inferior vena cava and enhances placental circulation and oxygen exchange.
Obtain vaginal specimen for alkali denaturation test (APT test), or use Kleihauer-Betke test to determine maternal serum, vaginal blood, or products of gastric lavage.When vaginal bleeding is present, differentiates maternal from fetal blood in amniotic fluid; provides a rough quantitative estimate of fetal blood loss and indicates implications for fetal oxygen-carrying capacity, and maternal need for Rh immunoglobulin G (RhIgG) injections, once delivery occurs. The Kleihauer-Betke test is more sensitive and quantitatively accurate than the APT test, but is time-consuming and may be impractical if the specimen is sent to an outside laboratory.
Carry out/repeat NST, as indicated.Electronically evaluating the FHR response to fetal movements is useful in determining fetal well-being (reactive test) versus hypoxia (nonreactive).
Assist with ultrasonography and amniocentesis. Explain procedures.Determines fetal maturity and gestational age. Aids in determining viability and realistically predicting outcome
Replace maternal fluid/blood losses.Maintains adequate circulating volume for oxygen transport. Maternal hemorrhage negatively affects uteroplacental oxygen transfer, leading to possible loss of a pregnancy or worsening fetal status. If oxygen deprivation persists, the fetus may exhaust coping mechanisms, and CNS damage/fetal demise can occur.
Administer supplemental oxygen to the client.Increases oxygen available for fetal uptake. The fetus has some inherent capacity to cope with hypoxia in that fetal Hb dissociates (releases oxygen at the cellular level) more rapidly than adult Hb, and the fetal red blood cell count is greater than that of the adult, so fetal oxygen-carrying capacity is increased.
Prepare client for appropriate surgical intervention as indicated.Surgery is necessary if placental separation is severe; or if bleeding is excessive, fetal oxygen deprivation is involved, and vaginal delivery is impossible, as in cases of total placenta previa (a low-lying placenta), where surgery may be indicated to save the life of the fetus.

Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

  • Muscle contractions/cervical dilatation
  • Tissue trauma

Possibly evidenced by

  • Verbalizations of pain
  • Distraction behaviors
  • Increased blood pressure/pulse rate

Desired Outcomes

  • Client will report pain/discomfort relieved or controlled.
  • Client will demonstrate use of relaxation skills/diversional activities
Nursing InterventionsRationale
Monitor nature, severity, location, and duration of pain. Assess for uterine contractions, retroplacental hemorrhage, or abdominal tenderness.Guides in diagnosis and choice of treatment. Pain related to spontaneous abortion and hydatidiform mole is caused by uterine contractions, especially during oxytocin infusion. In an ectopic pregnancy, the hemorrhage occurs when the fallopian tube rupture into the abdominal cavity which can lead to severe pain. Abruptio placentae is accompanied by severe pain, especially when concealed retroplacental hemorrhage occurs.
Assess client’s/couple’s psychological stress and emotional response to an event.During an emergency situation, anxiety may hasten the degree of discomfort due to the fear-tension-pain syndrome.
Educate client about the condition and treatment. Encourage expression of concerns.Information, knowing what to expect can help lower the anxiety level which can enhance the perception of pain.
Provide a quiet environment and diversional activities. Instruct client in relaxation methods such as meditation, guided imagery, and deep breathing.Decreases stimuli, refocus attention, hence lowering the level of discomfort.
Administer narcotics or sedatives as prescribed.Promotes rest/alleviates pain.
Prepare for surgical procedure, administer preoperative medications if indicated.Treatment of underlying disorder should alleviate pain.

Deficient Fluid Volume (Isotonic)

Deficient Fluid Volume: Decreased intravascular, interstitial, and intracellular fluid.

May be related to

  • Excessive vascular loss

Possibly evidenced by

  • Change in mentation
  • Decreased pulse pressure
  • Decreased/concentrated urine
  • Decreased venous filling,
  • Hypotension
  • Tachycardia

Desired Outcomes

  • Client will demonstrate improvement in fluid balance as evidenced by stable vital signs, good capillary refill, absence of alteration sensorium, and individually adequate urine output and specific gravity.
Nursing InterventionsRationale
Assess client history of blood loss (amount, duration, characteristics, and presence of clot). Instuct pad count; weigh pads/underpad.Estimation of the volume of blood loss aids in the differential diagnosis. A one gram of pad weight is equal to approximately 1 ml of blood loss.
Monitor uterine activity, fetal status, and any abdominal tenderness.Helps determine nature of the hemorrhage and possible outcome of a hemorrhagic episode. Tenderness is usually present in ruptured ectopic pregnancy or abruptio placentae.
Auscultate breath sounds.Adventitious breath sounds suggest an excessive replacement.
Monitor vital signs, capillary refill, color of mucous membranes/skin. Measure CVP, if feasible.Reflects the extent of blood loss, although cyanosis and changes in BP and pulse are late signs of circulatory loss and developing shock.
Record intake/output. Obtain hourly urine samples; measure specific gravity.Determines the degree of fluid losses and reflects the adequacy of renal perfusion.
Discourage rectal or vaginal examination.Promotes the occurrence of hemorrhage, especially if marginal or total placenta previa is considered.
Ascertain religious practices and preferences.May prohibit use of blood products and establish need for alternative therapy.
Position client appropriately, either supine with hips elevated or in semi-Fowler’s position for placenta previa. Avoid Trendelenburg position.Ensures adequate blood available to the brain. Elevating hips avoids compression of the vena cava, while semi-Fowler’s position allows the fetus to act as a tampon, controlling bleeding in placenta previa. Trendelenburg position may compromise maternal respiratory status.
Maintain client on strict bedrest. Instruct client to avoid Valsalva’s maneuver, or sexual intercourse.Bleeding may stop with a decrease in activity. Increased abdominal pressure or orgasm may stimulate bleeding.
Save expelled tissue or products of conception.Serves as evaluation for possible membrane retention; histologic examination may be required.
Monitor laboratory reports such as CBC, type and crossmatch, Rh titer, fibrinogen levels, platelet count, APTT, PT, and HCG levels.Determines the amount of blood loss and may provide information regarding the cause. Hct should be maintained above 30% to support oxygen and nutrient transport.
Insert indwelling catheter.Urine output of less than 30 ml/hr reflects decreased renal perfusion and possible development of tubular necrosis. Appropriate output is determined by individual degree of deficit and rate of replacement
Administer IV solutions, plasma expanders, whole blood, or packed cells, as indicated.Promotes increase circulating blood volume and reverses shock symptoms.
Prepare for D & C in the presence of hydatidiform mole or incomplete abortion.Removes any chorionic vessels or products of conception that may adhere to the endometrium.
Prepare for laparotomy in the case of ruptured ectopic pregnancy.Removal of the ruptured fallopian tube, and possibly the ovary, stops the hemorrhage.
Prepare for cesarean delivery if any of the following are diagnosed: severe abruptio placentae, DIC; or placenta previa when fetus is mature, vaginal delivery is not feasible, and bleeding is excessive or unresolved by bedrestHemorrhage stops once the placenta is removed and venous sinuses are closed.

Fear

Fear: Response to perceived threat that is consciously recognized as a danger.

May be related to

  •  Threat of death (perceived or actual) to self, fetus

Possibly evidenced by

  • Verbalization of specific concerns
  • Increased tension
  • Sympathetic stimulation

Desired Outcomes

  • Client will discuss fears regarding self, fetus, and future pregnancies, recognizing healthy versus unhealthy fears.
  • Client will verbalize accurate knowledge of the situation.
  • Client will demonstrate problem-solving and use resources effectively.
  • Client will report/display lessened fear and/or fear behaviors.
Nursing InterventionsRationale
Explain situation and understanding of the situation with client and partner.Provides information about the individual reaction to what is happening.
Determine religious/cultural practices.Client may desire, or refuse, baptism and burial of products of conception in event of inevitable abortion.
Monitor client’s/couple’s verbal and nonverbal responses.Indicates the degree of fear the client/couple is experiencing.
Listen and Active-Listen to client concerns.Promotes a sense of control over the situation and provides an opportunity for the client to develop own solutions.
Explain procedures and what symptoms mean.Knowledge can help to reduce fear and promote a sense of control over the situation.
Provide information in verbal and written form, and make opportunity for the client to ask questions. Answer questions honestly.Knowledge will help the client to cope more effectively with what is happening. Written information allows for review later because the client may not be able to assimilate information due to the level of anxiety. Honest answers promote better understanding and can reduce fear.
Involve client in planning and participating in care as much as possible.Being able to do something to help control the situation can reduce the fear.
Contact clergy/spiritual advisor, as appropriate.May be helpful in addressing some fears.

Deficient Knowledge 

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

  • Lack of exposure to, and unfamiliarity with, information resources

Possibly evidenced by

  • Request for information, statement of misconceptions, inappropriate or exaggerated behaviors

Desired Outcomes

  • Client will participate in learning process
  • Client will verbalize, in simple terms, the pathophysiology and implications of the clinical situation.
Nursing InterventionsRationale
Explain prescribed treatment and rationale for the hemorrhagic condition. Reinforce information provided by other healthcare providers.Provides information, clarifies misconceptions, and may aid in reducing associated stress.
Allow client opportunity to ask questions and verbalize misconceptions.Provides for clarification of misconceptions, identification of problems, and opportunity to begin to develop coping skills.
Discuss possible short-term maternal/fetal implications of bleeding episode.Provides information about possible complications, promotes realistic expectations, and enhances follow through with the treatment regimen.
Review long-term implications for situations requiring follow-up and additional treatment; e.g., hydatidiform mole, dysfunctional cervix,  or ectopic pregnancy.After the expulsion of a hydatidiform mole, HCG levels must be monitored for 1 yr. If levels remain high, chemotherapy is indicated, owing to the risk of choriocarcinoma. A client with repeated second-trimester spontaneous abortion may have a Shirodkar-Barter procedure performed. A client with an ectopic pregnancy may have difficulty conceiving after removal of the affected tube/ovary.

Risk for Excess Fluid Volume

Risk for Excess Fluid Volume: The state in which an individual is at risk of experiencing intracellular or interstitial fluid overload.

May be related to

  • Excessive/rapid replacement of fluid losses

Possibly evidenced by

  • [not applicable]

Desired Outcomes

  • Client will display BP, pulse, urine specific gravity, and neurological signs WNL, without respiratory difficulties.
Nursing InterventionsRationale
Assess neurological status, noting behavior changes or increasing irritability.Behavior changes may be an early sign of cerebral edema owing to water retention.
Monitor for increasing BP and pulse; note respiratory signs such as dyspnea, crackles, or rhonchi.If fluid replacement is excessive, symptoms of circulatory overload and respiratory difficulties may occur. In addition, the client with abruption placentae who may already have hypertension is at risk for manifesting negative response to fluid replacement, as is the client with compromised cardiac function.
Carefully monitor infusion rate manually or electronically. Record intake/output. Measure urine specific gravity.Intake and output should be approximately equal because circulating fluid volume is stabilizing. Urine output increases and specific gravity decreases as kidney perfusion and circulatory volume return to normal.
Assess Hct level.May indicate amount of blood loss and can be used to determine needs and adequacy of replacement

Risk of Maternal Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

May be related to

  • Abnormal blood profile
  • Tissue/organ hypoxia
  • Poor immune system

Possibly evidenced by

  • [not applicable]

Desired Outcomes

  • Client will display normal blood profile with WBC count, Hb, and coagulation studies within normal limit.
Nursing InterventionsRationale
Observe onset and amount of blood loss; Watch out for signs/symptoms of shock.Persistent, excessive hemorrhage may be life-threatening to the client or may result in postpartal infection, postpartal anemia, DIC, renal failure, or pituitary necrosis attributable to tissue hypoxia and malnutrition.
Assess for signs of bleeding from gums/mucous membranes or IV site.Indicates deficiencies or alterations in coagulation.
Monitor intake and output. Observe urine specific gravity.Reduced kidney perfusion results in reduced output. When hemorrhage occurs, the anterior pituitary lobe, which enlarges during pregnancy, is at risk for Sheehan’s syndrome.
Note temperature, WBC count, and odor and color of vaginal discharge, obtain culture if appropriate.Excessive blood loss with decreased Hb increases the client’s risk of developing an infection.
Provide information about risks of receiving blood products.Complications such as hepatitis and HIV/AIDS may not be manifested during hospitalization, but may require treatment at a later date.
Monitor for adverse response to administration of blood products, such as allergic or hemolytic reaction; treat per protocolEarly recognition and intervention may prevent a life-threatening situation.
Obtain blood type and crossmatch.Assures correct product will be available if blood replacement required.
Monitor coagulation studies (e.g., APTT, platelet count, fibrinogen levels, FSP/FDP).DIC with an associated drop in fibrinogen levels and a buildup of FSP may occur in response to the release of thromboplastin from placental tissue and/or dead fetus. In order for clot formation to occur, fibrinogen level must be at least 100 mg/dL.
Administer fluid replacement.Maintains circulatory volume to counteract fluid losses/shock
Administer antibiotic parenterally.May be indicated to prevent or minimize infection.
Administer heparin, if indicated.Heparin may be used in DIC in cases of fetal death, or of death of one fetus in a multiple pregnancy, or to block the clotting cycle by preserving clotting factors and reducing hemorrhage until surgical correction occurs.
Administer cryoprecipitate and fresh frozen plasma, as indicated. Avoid administration of platelets if consumption is still occurring (i.e., if platelet level is dropping).In clients with DIC, cryoprecipitate replaces most clotting factors. Administration of platelets during period of continued consumption is controversial, because it may perpetuate the clotting cycle, resulting in further reduction of clotting factors and increasing venous congestion and stasis.
Treat underlying problem (e.g., surgery for abruptio placentae or ectopic pregnancy, bedrest at home for placenta previa).Stops hemorrhage; reduces likelihood of maternal injury.

See Also

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