Nursing Care Plan

Presented to the Faculty of

San Pedro College

In Partial Fulfillment of the

Requirements in NCM 209 - RLE
DELIVERY ROOM ROTATION

Submitted to:
ANGELIQUE ANNE A. LOQUEZ, RN
Clinical Instructor

Submitted by:
MARY JUSTINE N. AFRICA, St. N
BSN 2E - Group 3

MAY 19, 2021

 Scenario:
A 27-year-old woman, gravida 2, para 1, was referred to our hospital with vaginal bleeding of 3 days’ duration. She had delivered her first infant
vaginally, a female weighing 4,100 g. The cervical OS was closed but a little fresh bleeding was seen. Ultrasonography demonstrated that the lower
placental edge overlapped the internal cervical OS by 33 mm and the patient was admitted for treatment at 16 weeks’ gestation. Bleeding continued
and increased gradually despite the intravenous administration of ritodrine hydrochloride for uterine contractions. The position of the placenta did not
change.
NURSING CARE PLAN

Name of Patient: A.B.C. Age/Sex: 27 YRS. OLD/ F Room/Bed # ST.

MARY-302

Chief Complaint: VAGINAL BLEEDING Physician: DR. LOQUEZ

Diagnosis (if discharged):

DATE CUES NEE NURSING PATIENT OUTCOME NURSING INTERVENTION IMPLEMENTATION EVALUATION
& D DIAGNOSIS
TIME
SUBJECTIVE: Within the hours of 1. Establish Rapport 1 MARCH 11, 2021 @
M - “Bigla nalang N Deficient Fluid R: to gain the GOAL MET
implementing the
A akong dinugo” U Volume related mother’s trust
Y as verbalized T Placenta Previa as nursing interventions After the hours of
by the patient R evidenced by active 2. Monitor vital signs 2 implementing the
the patient will be
19, I blood loss R: to obtain baseline nursing interventions
OBJECTIVE: T able to: data the patient was able
2 I RATIONALE: to:
0 ▪ Has bleeding O 3
 2 episodes N Fluid volume - maintain fluid 3. Asses color, odor, - maintain fluid
1 ▪ Abdomen is deficit is a state in consistency and amount of volume at a
volume at a
soft when & which an individual vaginal bleeding; weigh pads functional
7:00A palpated is experiencing functional level R: Provides level and has
M ▪ Manifests M decreased information about adequate
possibly
body E intravascular, active bleeding and urinary output
weakness T interstitial evidenced by old blood, tissue loss and stable
▪ Low blood A and/or intracellular and the degree of vital signs.
adequate
pressure B fluid. Active blood blood loss
▪ Increased O loss or urinary output 4
heart rate L hemorrhage due to 4. Assess hourly the intake and
and stable vital
▪ Decreased I disrupted placental output
respiratory S implantation during signs. R:.to avoid further
rate M pregnancy may bleeding, maintain
▪ Fetal heart manifest signs and blood pressure
rate less than symptoms of fluid levels, improve
normal vol. deficient that cardiac output.
▪ Decreased may later lead 5
urine output to hypovolemic 5. Provide adequate rest and
▪ Pale, cold, shock and cause reposition the mother
clammy skin maternal and fetal R: Provides
death. information about
maternal and fetal
physiologic Mary Justine N.
compensation to Africa, St. N
blood loss
6
6. Assess baseline data and
note changes. Monitor FHR.
R: Assessment
provides information
about
 possible infection, pla
centa previa or
abruption. Warm,
moist, bloody
environment is ideal
for growth of
microorganisms.
7
7. Assess abdomen for
tenderness or rigidity- if
present, measure abdomen at
umbilicus (specify time interval)
R: Detecting
increased in
measurement of
abdominal girth
suggests active
abruption

8
8. Assess SaO2, skin color,
temp, moisture, turgor, capillary
refill (specify frequency)
R: Assessment
provides information
about blood vol., O2
saturation and
peripheral perfusion

9. Assess for changes in LOC: 9

note for complaints of thirst or
apprehension
 R: To detect signs of
cerebral perfusion

10. Provide supplemental O2 10

as ordered via face mask or
nasal cannula @ 10-12 L/min.
R: Intervention
increases available
O2 to saturate
decreased
hemoglobin
11. Initiate IV fluids as ordered 11
(specify fluid type and rate).
R: For replacement
of fluid vol. loss

12. Position Pt. in supine with 12

hips elevated if ordered or
left lateral position.
R: Position
decreases pressure
on placenta and
cervical os.
Left lateral position
improves placental
perfusion

13. Monitor lab. Work as 13

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

13. Prepare the patient for C- 14

section and surgical
intervention related to maternal
bleeding
R: For heavy
bleeding, immediate
c-section will be
performed,
regardless if the fetus
is premature or in full
term. Corrective
surgery to control the
bleeding will also be
done and may
involve some surgical
approaches
appropriate to the
situation.
REFERENCES:
Ackley, B.J., Ladwig. G.B., Makic, M.B., Martinez-Kratz, M.R. (2020). Nursing diagnosis handbook; an evidence-based guide to planning care
Vera, M., By, -, Vera, M., & Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a full-time
writer and editor for Nurseslabs. During his time as a student. (2019, June 1). 3 Placenta Previa Nursing Care Plans. Nurseslabs.
https://nurseslabs.com/3-placenta-previa-nursing-care-plans/.
Nursestudynet@gmail.com. (2020, October 23). Placenta Previa Nursing Diagnosis Interventions and Care Plans. NurseStudy.Net.
https://nursestudy.net/placenta-previa-nclex-review-nursing-care-plans/.