ABRUPTIO PLACENTA

INEFFECTIVE TISSUE PERFUSION

ASSESSMENT DIAGNOSIS INFERENCE PLANING INTERVENTION RATIONALE EVALUATION

RELATED TO: Ineffective tissue One of the Short term: 1.Assess patient’s vital For baseline. Short term:
 Excessive perfusion related to symptoms of Affter 4 hours of signs,O2 saturation,and 1.These condition Patient shall
 blood loss excessive blood loss premature may indicate have verbalize
nursing intervention skin color.
secondary to separation of the decreased understanding
POSSIBLY ,the patient will
of
EVIDENCED BY: premature of placenta is uterine verbalize 2.Monitor for cerebral
condition,ther
 Loss of placental bleeding with a understanding of restlessness,anxiety,hun perfusion. apy
blood small amount to condition,therapy ger and changes in LOC. regimen,side
 FHR pattern moderate of dark- regimen,side effect 2.To obtain data effects of
 Altered PR red vaginal of medication,and 3.Monitor accurately about renal medication,an
severe bleeding in 80-85% when to contact I&O perfusion and d when to
abdominal cases.Bleeding may health care function and the contact health
pain and result to provider. 4.Monitor FHT extent of blood care provider.
rigidity hypervolemia and continuously loss.
coagulathy. Long term:
 Pallor LONG TERM:
3.To provide Patient shall
 Decrease After 2 days of 5.Assess uterine
nursing irritability,abdominal information have
urine
intervention,patient pain and rigidity regarding fetal demonstrate
output
distress and/or d life style
 Edema will demonstrate life
style 6.Assess skin worsening of changes/
 Delay in
changes/behavior color,temperature,mois condition behaviors
wound
that will improve ture,turgor,capillary that will
healing
circulation. refill 4.To determine improve
 Positive circulation.
the severity of
human’s
 sign 7.Elevate extremity the placenta
 Skin above that level of the abruption and
temerature heart bleeding

8.Teach patient not to 5.To determine

apply uterine pressure peripheral tissue
perfusion like
hypervolemia.

6.Helps promote
circulation.

7.Uterine
pressure can
cause pooling of
venousblood in
lower
extremities.

8.To immediately
provide
additional
intervention.
 RISK FOR SHOCK

ASSESSMENT DIAGNOSIS INFERENCE PLANING INTERVENTION RATIONALE EVALUATION

1.Assess for history or 1.The condition may

RELATED TO: presence of conditions deplete the body’s
leading circulating blood Maternal vital
 Significan to hypovolemic shock volume and the ability signs are all
t blood to maintain organ within the
loss of 2.Monitor for perfusion and normal range,
about persistent or heavy function.
fluid or blood loss.
especially the
10% of blood
2.The amount of fluid
the blood
volume
3.Assess vital signs or blood loss must be pressure.
and tissue and organ noted to determine the
 Separatio perfusion. extent of shock. Urine output
n of the should be
placenta 4.Review laboratory 3.For changes
data. associated with shock more than
 External states 30mL/hr.
or 5.Collaborate in
internal prompt treatment of 4.To identify potential
sources of shock and
No bleeding or
bleeding underlying conditions
and prepare for or degree of organ minimal
Possibly evidenced assist with medical involvement. amount of
by: and surgical bleeding
interventions. 5.To maximize
systemic circulation
observed.
 Vaginal and tissue and organ
6.oxygen by
bleeding appropriate route. perfusion. Uterus is not
 Couvelair tense and
e uterus 7.Administer blood or 6.To maximize rigid.
or a tense blood products as oxygenation of tissues.
and rigid indicated.
7.To rapidly restore or Fetal heart
uterus
8.Monitor uterine sustain circulating sounds are
 Increased contractions and fetal volume and electrolyte within the
balance.
 pulse rate heart rate by external 8.Assesses normal range.
monitor. whether labor or is
 Decrease present and fetal
d blood 9.Withhold oral fluid. status; external system
pressure avoids cervical
10.Measure intake and trauma.
 Increased
output.
respirator
9.Anticipates need for
y rate 11.Measure maternal emergency surgery
 Decrease blood loss by
d central weighing perineal 10.Enables assessment
venous pads and save any of renal function.
pressure tissue that has passed.
11.Provides objective
 Decrease 12.Maintain a positive evidence of amount
d urine attitude about fetal bleeding.
output outcome.
12.Supports mother-
 Decreasin 13.Provide emotional child bonding.
g level of support to the woman
conscious and her support 13.Assists problem
ness person. solving which is
lessened by poor self-
 Cold, esteem.
clammy
skin
 Fetal
bradycard
ia
 ACUTE PAIN

ASSESSMENT DIAGNOSIS INFERENCE PLANING INTERVENTION RATIONALE EVALUATION

 Assess for  To help
Related to: referred pain determine the
as possibility of
appropriate. underlying
 Sudden  Note client’s condition or
locus of organ
separation of control. dysfunction
placenta from  Note and requiring
investigate treatment.
the uterine wall changes from  Individuals
previous with external
reports of locus of
 Pain pain. control may
accompany  Acknowledge take little or
ing labor c the client’s no
ontractions description of responsibility
during pain and for pain
initial convey management.
separation acceptance of  To rule out
Possibly evidenced by: client’s worsening of
response to underlying
pain. condition or
 Sharp,  Monitor skin development
stabbing color and of
pain high temperature complications
in the and vital .
uterine signs.  Pain is a
fundus  Administer subjective
analgesics as experience
 Uterine indicated. and cannot
tenderness 
 Provide be felt by
Desired outcomes: comfort others.
measures,  These are
quiet usually
 Patient will environment, altered
report relief and calm in acute pain
or control activities.  To medicate
of pain.  Encourage as
adequate rest appropriate.
 Patient will periods.  To promote
follow
non
prescribed
pharmacologi
pharmacolo
cal pain
gical
management.
regimen.
 To maintain
 Patient will an acceptable
verbalize level of pain.
non  To
pharmacolo prevent fatigu
gical e
methods
that
provide
relief.
 Patient will
demonstrat
e use
of relaxatio
n skills and
diversional
activities as
indicated.