Placenta Previa NCP

1 Deficient Fluid Volume

Fluid volume deficit is a state in which an individual is experiencing decreased

intravascular, interstitial and/or intracellular fluid. Active Blood Loss or
Hemorrhage due to disrupted placental implantation during pregnancy may
manifest signs and symptoms of fluid vol. deficient that may later lead to
hypovolemic shock and cause maternal and fetal death.

Nursing Inter- Expected

Assessment Nursing Dx Planning Rationale
ventions Outcome
S- Deficient Short Term: 1. Establish 1. To gain Short Term:
Fluid Rapport patient’s trust
O- Volume r/t After 4 hours The pt shall
Active of NI, the pt 2. Monitor 2. To obtain have
Blood Loss will verbalize Vital Signs baseline data verbalized
> Bleeding understanding understanding
Secondary
Episodes
to Disrupted of causative of causative
(amount, factors. 3. Assess 3. Provides factors.
Placental
duration) color, odor, information about
Implantation
consistency and active bleeding
Long Term: amount of versus old blood, Long Term:
> Facial vaginal tissue loss and
Grimace due bleeding; weigh degree of blood
of Pain After 4 days pads loss The pt shall
of NI, the pt have
will maintain maintained
> Complaint fluid volume 4. Assess 4. Provides fluid volume
of pain at a hourly intake information about at a
functional and output. maternal and fetal functional
Abdomen level AEB physiologic level AEB
soft/hard individually compensation to individually
5. Assess
when adequate baseline data blood loss adequate
palpated urinary and note urinary
output and changes. output and
stable vital Monitor FHR. 5. Assessment stable vital
> Manifest signs. provides signs.
Body information about
Weakness 6. Assess possibleinfection,
abdomen for placenta previa or
tenderness or abruption. Warm,
> Low BP rigidity- if moist, bloody
present, environment is
Increased HR measure ideal for growth of
abdomen at microorganisms.
umbilicus
Decreased (specify time
RR interval) 6. Detecting
increased in
measurement of
Fetal HR 7. Assess abdominal girth
>120-160 SaO2, skin suggests active
bpm color, temp, abruption
moisture,
turgor, capillary
> Decreased refill (specify 7. Assessment
Urine Out frequency) provides
information about
blood vol., O2
> Increased 8. Assess for saturation and
Urine changes in peripheral
Concentration LOC: note for perfusion
complaints of
> Pale, Cool thirst or
Skin apprehension 8. To detect
signs of cerebral
perfusion
>Increased 9. Provide
Capillary supplemental
Refill O2 as ordered 9. Intervention
via facemask or increases available
nasal cannula O2 to saturate
@ 10-12 L/min. decreased
hemoglobin

10. Initiate IV
fluids as 10. For
ordered replacement of
(specify fluid fluid vol. loss
 type and rate). 11. Position
decreases pressure
on placenta and
11. Position cervical os. Left
Pt. in supine lateral position
with hips improves placental
elevated if perfusion
ordered or left
lateral position.
12. Lab. Work
provides
12. Monitor information about
lab. Work as degree of blood
obtained: Hgb loss; prepares for
& Hct, Rh and possibletransfusion.
type, cross Ultra sound
match for 2 provides info about
units RBCs, the cause of
urinalysis, etc. bleeding
Scheduled
forultrasound as
ordered.

–~~~~~~~~~~~~–

2 Decreased Cardiac Output

Placenta Previa is the development of placenta in the lower uterine segment

partially or completely covering the internal cervical os. Placenta Previa causes
bleeding. Due to large amounts of blood lost, the heart tries to pump faster in
order to compensate for blood loss. As a result, the heart pumps faster with
lesser blood pumped.

Nursing D Expected
Assessment Planning NursingInterventions Rationale
x Outcome
S- Decreased Short Term: Establish Rapport To gain Short Term:
cardiac patient’s
> output r/t After 4 hours Monitor Vital Signs trust The pt shall
dysrrhythmia altered of NI, the pt have
s contractilit will History taking participated
y participate in To obtain in activities
activities that baseline that reduce
> prolonged reduce the Assess patient condition data the
capillary workloadof workloadof
refill the heart. the heart.
Review lab data To
determine
> cold Long Term: Monitor BP & Pulse contributing Long Term:
clammy skin factors
frequently
After 4 days The pt shall
> Dyspnea of NI, the pt Provide information on test To assess have
will manifest procedures contributing manifested
hemodynami factors hemodynami
>
Restlessness c stability. c stability.
Provide adequate rest &
For
Reposition client
comparison
> variations
with current
in BP
readings Encouragerelaxationtechnique normal
s values

Elevate HOB To note

response to
activity
Encourage use
ofrelaxationtechniques
To gin pt’s
participatio
n

To promote
venous
return

To alleviate
stress &
anxiety

To promote
circulation

To decrease
tension
 level

–~~~~~~~~~~~~–

3 Ineffective Tissue Perfusion

Placenta Previa causes painless and continuous bleeding. With bleeding, there
is decreased Hemoglobin. Hemoglobin carries oxygen to different parts of the
body. If there is decreased Hemoglbin there is a failure to nourish the tissues
at the capillary level.

Assessme Nursing D Nursing Inter-

Planning Rationale Expected Outcome
nt x ventions
S- Ineffective Short Term: 1. Establish 1. To Short Term:
tissue Rapport gain
O- perfusion After 4 hours of NI, patient’s The pt shall have
r/t the pt will 2. Monitor Vital trust demonstratedbehavior
decreased demonstratebehavior Signs s to improve
> s to improve 2. To circulation.
HgB
Restlessne obtain
concentrati circulation.
ss 3. Assess patient baseline
on in blood
condition data Long Term:
&
Long Term:
> hypovolem
Confusion ia 4. Note 3. To The pt shall have an
After 4 days of NI, customary baseline assess increased perfusion as
Secondary the pt will data (usual BP, individually
> to placenta demonstrate contributi
weight, lab values) ng factors appropriate.
Irritability previa. increased perfusion
as individually
appropriate 5. Determine 4. For
> presence of
Manifest compariso
dysrrhythmias n with
Body
Weakness current
6. Perform findings
blanch test
>
Capillary 5. To
refill more 7. Check for identify
alterations
than 3 sec Homan’s Sign from
normal
> Oliguria 8. Encourage
quiet & restful 6. To
environment identify /
determine
adequate
9. Elevate HOB perfusion

10. Encourage use 7. To

of relaxationtechniq determine
ues presence
of
thrombus
formation

8. To
lessen O2
demand

9. To
promote
circulatio
n

10. To
decrease
tension
level