3 Abruptio Placentae Nursing Care Plans

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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.

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  1. Ineffective Tissue Perfusion
  2. Risk for Shock
  3. Acute Pain
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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 InterventionsRationale
Assess patient’s vital signs, O2 saturation, and skin color.For baseline data.
Monitor for restlessness, anxiety, hunger and changes in LOCThese conditions may indicate decreased cerebral perfusion
Monitor accurately I&OTo obtain data about renal perfusion and function and the extent of blood loss.
Monitor FHT continuouslyTo 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 refillTo determine peripheral tissue perfusion like hypervolemia.
Elevate extremity above the level of the heartHelps promote circulation.
Teach patient not to apply uterine pressureUterine 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 skinTo immediately provide additional interventions
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Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

Other recommended site resources for this nursing care plan:

Other care plans related to the care of the pregnant mother and her infant:

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Marianne is a staff nurse during the day and a Nurseslabs writer at night. She is a registered nurse since 2015 and is currently working in a regional tertiary hospital and is finishing her Master's in Nursing this June. As an outpatient department nurse, she is a seasoned nurse in providing health teachings to her patients making her also an excellent study guide writer for student nurses. Marianne is also a mom of a toddler going through the terrible twos and her free time is spent on reading books!
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