3 Abruptio Placentae Nursing Care Plans

August 31, 2016

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

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

Risk for Shock

Related to:

Significant blood loss of about 10% of the blood volume
Separation of the placenta
External or internal bleeding

Possibly evidenced by:

Vaginal bleeding
Couvelaire uterus or a tense and rigid uterus
Increased pulse rate
Decreased blood pressure
Increased respiratory rate
Decreased central venous pressure
Decreased urine output
Decreasing level of consciousness
Cold, clammy skin
Fetal bradycardia

Desired outcomes:

Patient will display hemodynamic stability.
Patient will regain vital signs within the normal range.
Patient will be able to verbalize understanding of disease process, risk factors, and treatment plan.
Patient will display a normal central venous pressure.
Patient’s skin is warm and dry.
Fetal heart rate is within normal range.
Patient will exhibit an adequate amount of urine output with normal specific gravity.
Patient will display the usual level of mentation.

Nursing Interventions	Rationale
Assess for history or presence of conditions leading to hypovolemic shock.	The condition may deplete the body’s circulating blood volume and the ability to maintain organ perfusion and function.
Monitor for persistent or heavy fluid or blood loss.	The amount of fluid or blood loss must be noted to determine the extent of shock.
Assess vital signs and tissue and organ perfusion.	For changes associated with shock states
Review laboratory data.	To identify potential sources of shock and degree of organ involvement.
Collaborate in prompt treatment of underlying conditions and prepare for or assist with medical and surgical interventions.	To maximize systemic circulation and tissue and organ perfusion.
Administer oxygen by appropriate route.	To maximize oxygenation of tissues.
Administer blood or blood products as indicated.	To rapidly restore or sustain circulating volume and electrolyte balance.
Monitor uterine contractions and fetal heart rate by external monitor.	Assesses whether labor is present and fetal status; external system avoids cervical trauma.
Withhold oral fluid.	Anticipates need for emergency surgery.
Measure intake and output.	Enables assessment of renal function.
Measure maternal blood loss by weighing perineal pads and save any tissue that has passed.	Provides objective evidence of amount bleeding.
Maintain a positive attitude about fetal outcome.	Supports mother-child bonding.
Provide emotional support to the woman and her support person.	Assists problem solving which is lessened by poor self-esteem.

Acute Pain

Related to:

Sudden separation of placenta from the uterine wall
Pain accompanying labor contractions during initial separation

Possibly evidenced by:

Sharp, stabbing pain high in the uterine fundus
Uterine tenderness

Desired outcomes:

Patient will report relief or control of pain.
Patient will follow prescribed pharmacological regimen.
Patient will verbalize non pharmacological methods that provide relief.
Patient will demonstrate use of relaxation skills and diversional activities as indicated.

Nursing Interventions	Rationale
Assess for referred pain as appropriate.	To help determine the possibility of underlying condition or organ dysfunction requiring treatment.
Note client’s locus of control.	Individuals with external locus of control may take little or no responsibility for pain management.
Note and investigate changes from previous reports of pain.	To rule out worsening of underlying condition or development of complications.
Acknowledge the client’s description of pain and convey acceptance of client’s response to pain.	Pain is a subjective experience and cannot be felt by others.
Monitor skin color and temperature and vital signs.	These are usually altered in acute pain.
Note when pain occurs.	To medicate as appropriate.
Provide comfort measures, quiet environment, and calm activities.	To promote non pharmacological pain management.
Administer analgesics as indicated.	To maintain an acceptable level of pain.
Encourage adequate rest periods.	To prevent fatigue.