Establish Rapport To gain patient’s trust

Monitor Vital Signs To obtain baseline data

Assess color, odor, consistency and amount of Provides information about active bleeding versus old
vaginal bleeding; weigh pads blood, tissue loss and degree of blood loss

Provides information about maternal and fetal

Assess hourly intake and output.
physiologic compensation to blood loss

Assessment provides information about

Assess baseline data and note changes. possible infection, placenta previa or abruption. Warm,
Monitor FHR. moist, bloody environment is ideal for growth of
microorganisms.

Assess abdomen for tenderness or rigidity- if

Detecting increased in measurement of abdominal girth
present, measure abdomen at umbilicus
suggests active abruption
(specify time interval)

Assess SaO2, skin color, temp, moisture, Assessment provides information about blood vol., O2
turgor, capillary refill (specify frequency) saturation and peripheral perfusion

Assess for changes in LOC: note for

To detect signs of cerebral perfusion
complaints of thirst or apprehension

Provide supplemental O2 as ordered via face Intervention increases available O2 to saturate

mask or nasal cannula @ 10-12 L/min. decreased hemoglobin

Initiate IV fluids as ordered (specify fluid type

For replacement of fluid vol. loss
and rate).

Position Pt. in supine with hips elevated if ordered Position decreases pressure on placenta and cervical os.
or left lateral position. Left lateral position improves placental perfusion

Monitor lab. Work as obtained: Hgb & Hct,

Lab Work provides information about degree of blood
Rh and type, cross match for 2 units RBCs,
loss; prepares for possible transfusion. Ultrasound
urinalysis, etc. Scheduled for ultrasound as
provides info about the cause of bleeding
ordered.

Establish Rapport
Monitor Vital Signs
Assess color, odor, consistency and amount of vaginal bleeding; weigh pads
Assess hourly intake and output.
Assess baseline data and note changes. Monitor FHR.
Assess abdomen for tenderness or rigidity- if present, measure abdomen at umbilicus
Assess SaO2, skin color, temp, moisture, turgor, capillary refill
Assess for changes in LOC: note for complaints of thirst or apprehension
Provide supplemental O2 as ordered via face mask or nasal cannula @ 10-12 L/min.
Initiate IV fluids as ordered
Position Pt. in supine with hips elevated if ordered or left lateral position.
Monitor lab. Work as obtained: Hgb & Hct, Rh and type, cross match for 2 units RBCs,
urinalysis, etc. Scheduled for ultrasound as ordered.

To gain patient’s trust

To obtain baseline data
Provides information about active bleeding versus old blood, tissue loss and degree of blood loss
Provides information about maternal and fetal physiologic compensation to blood loss
Assessment provides information about possible infection, placenta previa or abruption. Warm,
moist, bloody environment is ideal for growth of microorganisms.
Detecting increased in measurement of abdominal girth suggests active abruption
Assessment provides information about blood vol., O2 saturation and peripheral perfusion
To detect signs of cerebral perfusion
Intervention increases available O2 to saturate decreased hemoglobin
For replacement of fluid vol. loss
Position decreases pressure on placenta and cervical os. Left lateral position improves placental
perfusion
Lab Work provides information about degree of blood loss; prepares for possible transfusion.
Ultrasound provides info about the cause of bleeding