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Abruptio Placentae Nursing Care Plan: Nursing Case Study

Thursday, 3 April 2014

Abruptio placentae refers to the premature separation of a normally implanted placenta from the uterine wall.

Nursing care plan
Nursing diagnosis
Nursing priorities

Deficient fluid volume related to bleeding
     Observe for and prevent or promptly treat hemorrhage.


Acute pain related to uterine tonicity, fundal tenderness, and unrelenting, uncharacteristic uterine contractions
     Promptly detect and intervene to reduce pain.

Fear related to fetal distress and possible fetal death
     Evaluate emotional status and provide support.


Risk for injury (fetal) related to uteroplacental hemorrhage and compromised gas exchange
     Monitor for and treat fetal distress.



Other potential nursing diagnoses: Ineffective coping related to fear of fetal distress or death Compromised family coping related to fear of fetal distress or death Deficient knowledge related to disease process




Deficient fluid volume related to bleeding
Expected outcome
The patient will experience minimal bleeding, remain normovolemic, and maintain optimal tissue perfusion.
Suggested NOC Outcomes
Blood loss severity: Vaginal bleeding; Fluid balance; Tissue perfusion: Peripheral
Nursing interventions
Intervention type
Intervention
Rationale
Independent





Record onset and amount of vaginal bleeding before admission. Assess bleeding every 30 minutes or as the patient's condition warrants. Note color of blood and number of perineal pads used and their degree of saturation and weight.

Accurate assessment helps estimate blood loss and replacement needs. (Note: 1 g of blood by weight equals 1 ml; a saturated pad equals approximately 100 ml.) Blood loss may be as much as one-half the pregnant blood volume.
Independent
Monitor vital signs and compare with baseline.

The patient may lose 500 to 600 ml of blood before arterial blood pressure or cardiac output is significantly affected. Maternal hypervolemia, hypertension, and initial compensatory mechanisms may mask restlessness, tachycardia, hypotension, and tachypnea—all signs of shock.
Independent
Perform capillary blanch test and note pulse pressure.

Decreased refill time in the capillary blanch test indicates decreased peripheral circulation. Narrowing pulse pressure indicates early shock.
Independent
Measure fundal height from the superior aspect of the symphysis pubis to the top of the uterine fundus every 30 minutes.
Fundal height reflects gestational age. An increase may indicate blood trapped behind the placenta.
Independent
Monitor for frank bleeding, ecchymoses, petechiae, hematomas, and bleeding from mucous membranes or sites of invasive procedures.
These signs and symptoms may indicate disseminated intravascular coagulation (DIC), requiring prompt medical intervention.
Collaborative
Obtain and monitor Hb level and HCT, as ordered.
Decreasing levels may signal blood loss.
Collaborative
Obtain and monitor coagulation factors, noting:
■ PT longer than 15 seconds
■ PTT longer than 60 seconds
■ fibrinogen levels less than 150 mg/dl
■ platelet count less than 100,000/mm3
■ fibrinogen degradation products greater than 100 mg/ml.
These results suggest DIC, which requires prompt blood replacement and correction of the underlying pathology.

Collaborative



Start an I.V. infusion of crystalloid or normal saline solution using a large‑bore needle, as ordered.
Rapid fluid replacement is needed to correct hypovolemia. The patient should receive fluids while waiting for typing and crossmatching of blood products.
Independent

Monitor fluid intake and output and urine specific gravity every hour.

Fluid intake and output measurements allow assessment of kidney function. Decreased kidney perfusion may result in renal failure. Decreased urine output and urine specific gravity indicate impending or actual renal failure.
Collaborative
Obtain and monitor creatinine clearance and BUN and creatinine levels.
Decreased creatinine clearance and increased BUN and creatinine levels indicate impending or actual renal failure.
Collaborative
Monitor central venous pressure (CVP), as ordered.
Normal CVP readings during pregnancy range from 8 to 10 cm H2O. Readings of 15 to 20 cm H2O indicate circulatory overload.
Collaborative
Administer packed red blood cells, cryoprecipitate, plasma, or platelets, as ordered.

The patient may need a large amount of blood to replace lost volume. Plasma or cryoprecipitate may be given to correct decreasing fibrinogen levels.
Collaborative
Maintain nothing-by-mouth (NPO) status, if ordered.
NPO status prevents aspiration of stomach contents during surgery.
Independent
Perform uterine massage and note uterine contractility (postpartum).

Massage stimulates contraction. Decreased uterine contractility, coupled with blood between the myometrial fibers, is characteristic of Couvelaire uterus. Trapped blood makes the uterus feel deceptively firm.
Independent
Maintain bed rest, with the patient in the left lateral position, if possible, or at least with a left tilt. Elevate the feet 30 degrees.

Bed rest decreases physiologic and metabolic demands. The left lateral position decreases pressure on the vena cava, augmenting venous return and cardiac output. Elevating the feet increases blood flow to vital organs.
Collaborative
Administer oxygen, as ordered.

Supplemental oxygen enhances tissue perfusion at the alveolocapillary membrane.

[Additional individualized interventions]

Suggested NIC Interventions
Bleeding reduction: Antepartum uterus; Fluid management; Fluid monitoring; Laboratory data interpretation; Oxygen therapy; Positioning; Shock management: Volume; Vital signs monitoring
Acute pain related to uterine tonicity, fundal tenderness, and unrelenting, uncharacteristic uterine contractions
Expected outcome
The patient will experience minimal pain.
Suggested NOC Outcomes
Comfort level; Pain control; Pain level
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Establish a rapport with the patient and her partner. Call the patient by her preferred name and frequently check on her.
A positive relationship builds trust and decreases anxiety, which can in turn decrease pain perception.
Independent
Assess for pain, including quality, frequency, location, and intensity.

A pain profile may indicate the degree and severity of the abruption.
Independent
Minimize distracting environmental stimuli.

External stimuli may increase the perception of pain. Interruptions of rest periods may weaken the patient's emotional reserves.
Independent

Perform comfort measures, including position changes, relaxation techniques, and massage and effleurage.
Increased tissue perfusion and stimulation of afferent fibers can decrease the perception of pain.
Collaborative
Administer pharmacologic analgesia, as ordered.

Analgesics are used to relieve pain but are used cautiously because they can compromise fetal status.

[Additional individualized interventions]

Suggested NIC Interventions
Analgesic administration; Environmental management; Pain management
Fear related to fetal distress and possible fetal death
Expected outcome
The patient will express less fear.
Suggested NOC Outcomes
Coping; Fear level
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Provide information in a clear, forthright manner, and allow the patient to ask questions. Ascertain the patient's understanding of the information.

Open communication gives the patient a sense of control and helps decrease her fear. Infant survival depends on gestational age and maturity and the extent or severity of abruption. A realistic appraisal of the deteriorating stability of the undeveloped fetus allows the patient to begin the grieving process.
Independent
Involve significant others in teaching and in providing comfort measures for the patient, if she permits.
The presence and support of loved ones can decrease fear.

[Additional individualized interventions]

Suggested NIC Interventions
Emotional support; High-risk pregnancy care; Presence
Risk for injury (fetal) related to uteroplacental hemorrhage and compromised gas exchange
Expected outcome
The patient will experience minimal risk of fetal injury.
Suggested NOC Outcomes
Fetal status: Antepartum
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Assess fetal status with each maternal assessment, including fetal heart rate (FHR) patterns and variability and fetal activity. Compare with baseline.

Indicators of fetal distress include hyperactivity; slow, irregular FHTs that are clinically difficult to hear; late decelerations; and increased FHR with decreased variability.

[Additional individualized interventions]

Suggested NIC Interventions
Electronic fetal monitoring: Antepartum
EXPECTED OUTCOME
The preterm neonate will be delivered safely.
Suggested NOC Outcomes
Fetal status: Intrapartum; Knowledge: Labor & delivery; Newborn adaptation
Nursing interventions
Intervention type
Intervention
Rationale
Collaborative
Administer drugs to bring about labor, as ordered. Monitor the progress of labor.

Oxytocin infusion or amniotomy can be used to help bring about a vaginal delivery, which is preferable if the fetus has died and if DIC is probable. If the cervix isn't ripe or if fetal distress occurs, the fetus should be delivered by cesarean section. Prompt delivery of a compromised fetus is critical to its survival.
Independent
Notify pediatric and neonatal staff of the impending delivery. Obtain the necessary resuscitative equipment.



The ability of the fetus to survive outside the uterus depends on its gestational age and respiratory, neurologic, thermoregulatory, and GI maturity. Aggressive resuscitation and sustained intensive care may be required.

[Additional individualized interventions]

Suggested NIC Interventions
Cesarean section care; Electronic fetal monitoring: Intrapartum; Labor induction

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