Abruptio placenta, also called placental abruption, is where the placenta separates from the uterine wall prematurely, usually after the 20th week of gestation, producing hemorrhage. It is a common cause of bleeding during the second half of pregnancy. Firm diagnosis, in the presence of heavy maternal bleeding, may indicate termination of pregnancy. Fetal prognosis depends on the gestational age and amount of blood lost; maternal prognosis is good if hemorrhage can be controlled.
Nursing Care Plans
Nurses play a vital role in preventing complications for patients with abruptio placentae. Accurate assessment and prompt intervention will promote a safe delivery of the newborn.
Here are three (3) nursing care plans and nursing diagnosis for patients with abruptio placentae.
Ineffective Tissue Perfusion
Nursing Diagnosis
Related to:
- Excessive blood loss
Possibly 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 color. | For baseline data. |
| Monitor for restlessness, anxiety, hunger and changes in LOC | These conditions may indicate decreased cerebral perfusion |
| Monitor accurately I&O | To obtain data about renal perfusion and function and the extent of blood loss. |
| Monitor FHT continuously | To provide information regarding fetal distress and/or worsening of condition |
| Assess uterine irritability, abdominal pain and rigidity. | To determine the severity of the placental abruptio and bleeding |
| Assess skin color, temperature, moisture, turgor, capillary refill | To determine peripheral tissue perfusion like hypervolemia. |
| Elevate extremity above the level of the heart | Helps promote circulation. |
| Teach patient not to apply uterine pressure | Uterine pressure can cause pooling of venous blood in lower extremities |
| Instruct patient and/or SO to report immediately signs and symptoms of thrombosis: (1) pain in leg, groin (2) unilateral leg swelling (3) pale skin | To immediately provide additional interventions |
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans related to the care of the pregnant mother and her infant:
- Abruptio Placenta | 3 Care Plan
- Abortion (Termination of Pregnancy) | 8 Care Plans UPDATED!
- Cesarean Birth | 10 Care Plans UPDATED!
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Gestational Diabetes Mellitus | 8 Care Plans UPDATED!
- Hyperbilirubinemia (Jaundice) | 4 Care Plans UPDATED!
- Labor Stages, Induced and Augmented Labor | 36 Care Plans UPDATED!
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans UPDATED!
- Postpartum Thrombophlebitis | 5 Care Plans UPDATED!
- Prenatal Hemorrhage | 9 Care Plans UPDATED!
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Preeclampsia and Gestational Hypertension | 6 Care Plans UPDATED!
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 7 Care Plans UPDATED!
- Puerperal & Postpartum Infections | 5 Care Plans UPDATED!