ASSESSMENT

NSG. DIAGNOSIS

SCI. EXPLANATION Risk factors

PLANNING

INTERVENTION

RATIONALE

EVALUATION

ABRUPTIO PLACENTA Subjective data:

Acute pain related to collection of blood between uterine wall and placentas evidenced by sharp, stabbing pain at epigastric area.

Short term: After 2 hrs. of nursing intervention, the client will be able to:

Independent: Monitor amount of To measure the bleeding by weighing amount of blood loss. all pads.

Discharge outcome: After 2 days, the client: -reported controlled pain. -vital signs in normal range.

Premature separation of the placenta

Objective data: sharp, stabbing pain at epigastric area. Presence of uterine rigidity and tenderness Painful, tender, tense (board-like) abdomen Crying Attention is distracted BP: 80/50 PR: 58 RR: 16

Pooling of blood under the placenta

Blood infiltrates the uterine musculature

Hard,boardlike uterus

Uterus become tense and feels rigid to touch

-report reduction of Investigate pain Changes in location pain into tolerable level reports, noting or intensity are not location, duration, uncommon but may -perform 3/5 nonintensity (0-10 scale), reflect developing pharmacologic pain and characteristics complications. management (dull, sharp, constant). Discharge outcome: Monitor maternal Early recognition of After 2 days, the client vital signs and fetal possible adverse will be able to: heart rate through effects allows for continuous prompt intervention. -report absence of pain. monitoring. -maintain vital signs in normal range. Measure and record Fundal height may fundal height. increase with concealed bleeding. Position mother in the left lateral position, with the head of the bed elevated. Provide comfort measure like back rubs, deep breathing. To enhance placental perfusion.

Short term: After 2 hrs, the client: -reported pain reduction. -verbalized 3 non pharmacologic pain management. GOAL ACHIEVED

Pain on epigastric area

Promotes relaxation and may enhance patients coping abilities by refocusing attention.

Collaborative: Administer oxygen as To supply adequate indicated oxygen to the fetus and mother and prevents further complication.

ABAINZA, Rochelle Marie T. ASSESSMENT NSG. DIAGNOSIS SCI. EXPLANATION Increased cardiac out put PLANNING INTERVENTION RATIONALE EVALUATION

PIH Subjective Data:

Objective Data: Generalized edema Decrease Hct and platelet level Epigastric pain Feet edema +2 Proteinuria of 300 mg/ L Urine output of 500 mL/ 24 hr.

Deficient fluid volume related to plasma protein loss secondary to PIH as evidenced by proteinuria of 300 mg/L and generalized edema.

Short Term Goal: After 8 hrs of nursing intervention, the client will be able to:

Independent: Weigh client routinely. Encourage client to monitor weight at home between visits. Sudden, significant weight gain (e.g., more than 3.3 lb (1.5 kg)/month in the second trimester or more than 1 lb (0.5 kg)/wk in the third trimester) reflects fluid retention. Fluid moves from the vascular to interstitial space, resulting in edema.

Discharge outcome: After 4 days, the client: Was free from generalized edema Has Hct and platelet level within normal range Have absence of proteinuria and 30 cc of urine output per hr.

Injury to endothelial cells of arteries

Show decrease facial and feet edema from +2 to +1. Verbalize understanding of need for close monitoring of weight, BP, urine protein, and edema. Discharge Outcome: After 4 days, the client will be able to:

Decreased responsiveness of the blood vessels to blood pressure

Vasospasm Interstitial effects

Distinguish between physiological and pathological degree of pitting.

Diffusion of fluid from Be free of signs of generalized edema: blood stream into (epigastric pain, interstitial tissue cerebral symptoms, dyspnea, nausea/vomiting) Edema Display Hct and platelet level within normal range.

The presence of Short Term Goal: pitting edema (mild, 1+ to 2+; severe, 3+ to Has decreased edema 4+) of face, hands, up to grade of +1. legs, sacral area, abdominal wall, or Verbalized edema that does not understanding of disappear after 12 hr need for close of bed rest is monitoring of weight, significant. Note: BP, urine protein, and Significant edema edema. may actually be present in non-pre eclamptic clients and absent in clients with mild or moderated

PIH. Showed absence of proteinuria and has a urine output of at least 30 cc/ hr. Note changes in Hct/Hb levels. Identifies degree of hemoconcentration caused by fluid shift. If Hct is less than 3 times Hb level, hemoconcentration exists.

Reassess dietary Adequate nutrition intake of proteins and reduces incidence of calories. Provide prenatal hypovolemia information as and hypoperfusion; needed. inadequate protein/calories increases the risk of edema formation and PIH. Intake of 80100 g of protein may be required daily to replace losses. Monitor intake and output. Note urine color, measure specific gravity as indicated. Urine output is a sensitive indicator of blood volume. Oliguria and specific gravity of 1.040 indicate severe hypovolemia and kidney involvement. Note: Administration of magnesium sulfate (MgSO4) may cause transient increase in output. Lateral recumbent

Place client on strict

regimen of bedrest; encourage lateral position.

position decreases pressure on the vena cava, increasing venous return and circulatory volume. This enhances placental and renal perfusion, reduces adrenal activity, and may lower BP as well as account for weight loss through diuresis of up to 4 lb in 24-hr period.

Collaborative: Replace fluids either Fluid replacement orally or parenterally corrects hypovolemia, via infusion pump, as yet must be indicated. administered cautiously to prevent overload, especially if interstitial fluid is drawn back into circulation when activity is reduced. With renal involvement, fluid intake is restricted; i.e., if output is reduced (less than 700 ml/24 hr), total fluid intake is restricted to approximate output plus insensible loss. Use of infusion pump allows more accurate

control delivery of IV fluids.