NURSING CARE PLAN
Patient’s Initials: Mrs. C
Age & Gender: 31 yrs./o, Female
Birthdate: January 31, 1991
Address: San Carlos City, Pangasinan
ASSESSMENT
SUBJECTIVE:
“Nurse, bigla na lang akong
dinugo pero hindi ko
naramdaman. Masyadong
mapula na may halong itim
ang kulay ng nailabas kong
dugo” as verbalized by the
patient.
OBJECTIVE:
The woman has a known twin
gestation and has an
ultrasound findings with vasa
previa.
VITAL SIGNS
NURSING ANALYSIS
Vasa previa occurs when
fetal blood vessels that
are unprotected by the
umbilical cord or placenta
run through the amniotic
membranes and traverse
the cervix. These vessels
may rupture if the
membranes break,
resulting in fetal bleeding,
exsanguination, or
possibly death.
Chief Complaint: “Nurse, bigla na lang akong dinugo pero Name of Student Nurse: CASSANDRA GRACE M.
hindi ko naramdaman. Masyadong mapula na may halong DELA CRUZ
itim ang kulay ng nailabas kong dugo”
Admitting Diagnosis: Vasa Previa Level/Block/Group: 2BSN-22
Hospital/Area: Blessed Doctor’s Hospital/ OB-
Gyne Area
Date of Confinement: February 12, 2022 Clinical Instructors: Mrs. Maria Via J. Lucena
MSN, RN, LPT, Mrs. Arlene Dacanay RN, Ms.
Kathrina Luiza Manor RN, and Ms. Angelie
Grace Bartolome,RN and Mrs. Violeta Gutierrez
RN
PLANNING INTERVENTIONS RATIONALE EVALUATION
Short term: After 1-2 INDEPENDENT: Short term:
hours of nursing The goal met
1) Monitor the vital signs of 1. To obtain baseline
intervention, the
the twin fetus. Auscultate status of fetal well-being. Short term: After 1-2 hours
following must be
and report FHR; note Assess the degree of of nursing intervention, the
attained:
bradycardia or tachycardia. fetal hypoxia. Initial following was attained:
• Plan for Note change in hypoactivity response of a fetus to
immediate or hyperactivity. decreased oxygenation is • Had an emergency
Cesarean tachycardia and Cesarean Section.
Section increased movements. A • The babies are
• The babies further deficit will result safely delivered.
will be in bradycardia and • There were no
delivered decreased activity. Non- indicators of fetal
safely.
BP- 110/70 mmHg
PR- 80 bpm
RR- 18 bpm
Fundal Height: 41 cm
Cervix: 4 cm and after 2 hours
of labor, dilates to 6 cm
Effacement: 90%
Presenting Part: Vertex/vertex
FHR: 140 bpm increases to
170 bpm
NURSING DIAGNOSIS
Risk for fetal death related to
the presence of vasa previa
• There will be reassuring findings need distress for the
no indicators immediate intervention. newborns.
of fetal
distress for
the newborns 2. Assess the condition of 2. Assessing the
the twin fetus and do a conditions may help to
prenatal monitoring. identify the contributing
Long term: After 3-4 Long term:
factors. Prenatal
days of nursing The goal met.
monitoring may help to
intervention, the
detect cord compression Long term: After 3-4 days of
following must be
and determine whether nursing intervention, the
attained:
the fetus is in distress. following was attained:
• Upon
3. Observe for the possible 3. Early observation • Upon discharge, the
discharge,
complications that might could be beneficial to newborns’
the
occur in the condition of recognize the possible examination
newborns’
vasa previa (such as fetal risk that might findings were
examination
bleeding, prolapsed cord, complicate the condition normal.
findings will
fetal distress etc). Record of the twin fetus.
be normal.
the findings and report it Reporting the findings
immediately to the may help to formulate a
physician. good care plan.
4. Encourage the mother to 4. To assess the fetus,
do an early and frequent detect certain
ultrasound examination. abnormalities and
determine the possible
complications early.
5. Do a complete physical 5. Assessing the
exam to the neonates after neonates after birth is
relevant to identify their
well-being. Finding any
birth for signs of problems
or complications.
DEPENDENT:
5. Administer
corticosteroids.
6. Pelvic rest may be
advised (avoiding sex or
putting anything in your
vagina).
COLLABORATION:
7.) Perform immediate
Cesarean Section delivery.
problems could help the
healthcare provider to
plan the best possible
care.
5. Steroids may help to
mature the baby’s lungs
in case they need to be
delivered early.
6. Pelvic rest may help to
avoid risks and
complications.
7. Vaginal delivery can
pinch the blood vessels
which cuts off the blood
flow to the baby.
Cesarean Section is
preferred to help the
woman avoid dangerous
delivery-room situations
and can be a lifesaver in
an emergency.