ABRUPTIO PLACENTA

ASSESSMENT DIAGNOSIS INFERENCE PLANING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective tissue One of the Short term: 1.Assess patient’s vital 1.These condition Short term:
perfusion related to symptoms of Affter 4 hours of signs,O2 saturation,and may indicate Patient shall
“Dinudugo excessive blood loss premature have verbalize
nursing intervention skin color. decreased
ako.Marami nang secondary to separation of the understanding
,the patient will cerebral
lumalabas sa of
premature of placenta is uterine verbalize 2.Monitor for perfusion.
akin.Nakaka lima condition,ther
placenta bleeding with a understanding of restlessness,anxiety,hun
akong diaper sa isang apy
araw.” As verbalized small amount to condition,therapy ger and changes in LOC. 2.To obtain data regimen,side
by the patient. moderate of dark- regimen,side effect about renal effects of
red vaginal of medication,and 3.Monitor accurately perfusion and medication,an
bleeding in 80-85% when to contact I&O. function and the d when to
Objective: cases.Bleeding may health care extent of blood contact health
result to provider. 4.Monitor FHT loss. care provider.
 Profuse hypervolemia and continuously.
vaginal coagulathy. Long term:
bleeding
LONG TERM: 3.To provide
After 2 days of 5.Assess uterine information Patient shall
hour prior to have
admission. nursing irritability,abdominal regarding fetal
intervention,patient pain and rigidity. distress and/or demonstrate
 Evacuated
will demonstrate life worsening of d life style
blood clots of
300ml. style 6.Assess skin condition. changes/
 Increased HR changes/behavior color,temperature,mois behaviors
of 110 bpm that will improve ture,turgor,capillary 4.To determine that will
 BPof 180/100 circulation. refill. the severity of improve
 Pale the placenta circulation.
palpebral 7.Elevate extremity abruption and
conjunctive above that level of the bleeding.
heart
5.To determine
8.Teach patient not to peripheral tissue
apply uterine pressure perfusion like
hypervolemia.

6.Helps promote
circulation.

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

8.To immediately
provide
additional
intervention.
ASSESSMENT DIANOSIS INFERENCE PLANING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain related to Abruptio placenta is After 8 hours of Independent:  To After 8 hours
Collection of blood premature nursing  Monitor amount measure of nursing
“Bigla na lang between uterine wall separation ot the intervention,the of bleeding by the intervention,t
sumakit ng matindi and placenta. normally implanted patient will weighing all pads. amount of he patient
ang tiyan ko,kahit 22 placenta in the third demonstrate use of blood loss was able to
linggo palang ang trimester.There are relaxation  Investigate pain demonstrate
ipinagbubuntis two types of skills,other methods reports,noting  Changes in use of
ko”(Im 22 weeks abruption placenta; to promote comfort. location,duration location or relaxation
pregnant and I feel a concealed intensity (0-10 intensity skills,other
sharp pain in my hemorrhage and scale),and are not methods to
abdomen)as external characteristics uncommon promote
verbalized by the hemorrhage.With a (dull,sharp,consta but may comfort.
patient. concealed nt). reflect
hemorrhage,the developing
placenta separation  Monitor maternal complicatio
centrally, and a large vital signs and n
Objective: amount of blood is fetal heart rate
accumulated under through  Early
 Abdominal the placenta.When continuous recognition
guarding. an external monitoring. of possible
 Muscle hemorrhage is adverse
tension present,the  Measure and effect
 Irritability. separation is record fundal allows for
 V/S taken as membranes and height. prompt
follows: through interventio
cervix.Women at risk  Positon mother in n.
T:37.3 for developing the left lateral
P:95 abruption placenta position,with the  Fundal
R:22 include those with head of the bed height may
BP:100/70 history of elevated. increase
hypertension or with
pervious abruption concealed
placenta,abdominal  Provide comfort bleeding.
trauma during measure like back
pregnancy, anomaly rubs,deep  To enhance
of the umbilical brething.Instruct placental
cord,uterine in relaxation or perfusion.
fibroids,advanced visualization
maternal exercise.Provide  Promotes
age,cigarette divisional relaxation
smoking,and cocaine activities. and may
abuse. enhance
Collaborative: patien’s
coping
 Administer oxygen abilities by
as indicated. refocusing.

 To supply
adequated
oxygen to
the fetus
,mother
,and
prevents
further
complicatio
n.
ASSESSMENT DIAGNOSIS INFERENCE PLANING INTERVENTION RATIONALE EVALUATION

Subjective: Imbalanced Nutrition Biologic, psychologic, After 2 weeks of Independent: Patients may be
Less than Body economic factors nursing intervention,  Obtain unaware of their
Patient verbalizes “I Requirements Related ↓ the patient will be nutritional actual weight or
always feel weak and To Inability to ingest Impair a person’s able to: history; weight loss due to
tired” or digest food or to ability to ingest or  Verbalize and include family, estimating weight
absorb nutrients digest food/ absorb demonstrate significant
because of biologic, nutrients selection of Patient's
others, or
Objective: psychologic, or ↓ foods or perception of
Document
economic factors Imbalanced Nutrition meals that will actual intake
Weight loss (less than body actual weight
achieve a may differ.
Poor muscle tone requirements) using
cessation of weighing With proper
Vital signs: weight loss. scale; do not assessment you
t- 37 C  Have weight estimate may be able to
P- 59 bpm within 10% of  caregiver in plan appropriate
Rr – 17 br/min ideal body assessment. interventions
BP 90/60 mmHg weight.
 Determine (i.e., patients
etiologic with dentation
factors for problems may
reduced require referral
nutritional to a dentist)
intake
Many
 Monitor or
psychological,
explore
psychosocial,
attitudes
and cultural
toward eating
factors
and food.
determine the
 Encourage
type, amount,
patient
and
participation
appropriateness
 in recording of food
food intake consumed.
using a daily
Determination
log.
of type, amount,
 Monitor
and pattern of
patient daily
food or fluid
or weekly
intake as
 Provide
facilitated by
companionshi
accurate
p during
documentation
mealtime.
by patient or
 Build up and
caregiver as the
persuade a
intake occurs;
pleasing
memory is
milieu for
insufficient.
meals. Dish up
foods in well- During
ventilated, aggressive
pleasing nutritional
environment, support, patient
with can gain up to
unhurried 0.5 lbs per day.
ambiance,
Attention to the
friendly
social aspects of
company.
eating is
 Give frequent
important in
mouth care,
both the
noting
hospital and
secretion
home setting.
precautions.
Prevent us of Pleasing milieu
 alcohol- helps in
containing lowering stress
mouthwashes and is more
 Encourage favorable to
exercise as eating. It also
indicated encourages
Collaborative. socialization and
 Ask dietician maximizes
for further patient comfort
evaluation when eating
and difficulty cause
suggestions discomfiture.
regarding
food Lowers
partialities discomfort
and related with
nutritional nausea or
assistance. vomiting, oral
lesions, mucosal
dryness, and
halitosis. Clean
mouth may
improve
appetite

Metabolism and
utilization of
nutrients are
enhanced by
activity.

Dieticians have a
broader knowledge
of the nutritional
value of foods and
may be useful in
evaluating specific
ethnic or cultural
foods.
 PULMONARY EMBOLISM
ASSESSMENT DIAGNOSIS INFERENCE PLANING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective Breathing Ineffective Breathing After 4 hours of Note emotional responses Anxiety may be After 4 hours
Pattern r/t decreased Pattern is one of the nursing intervention (e.g., gasping, crying, causing/exacerba of nursing
“Dyspnea,Insipatory lung expansion as issues nurses need to the patient was be reports of tingling fingers) ting acute or intervention
chest pain,Cough and evidenced by dyspnea focus on. It is able to establish a the patient
considered the state chronic
hemoptysis”as and cough. normal/effective was be able to
in which the rate, hyperventilation
complained by the respiratory pattern as establish a
patient. depth, timing, and evidenced by absence normal/effecti
rhythm, or the pattern of cyanosis and other ve respiratory
Objective: of breathing is signs/symptoms of To correct pattern as
Have client breathe into a
altered. When the hyperventilation
hypoxia with ABGs paper bag, if appropriate, evidenced by
breathing pattern is
 Dyspnea. ineffective, the body
normal/acceptable (Research absence of
 Prolonged is most likely not range. suggests this may cyanosis and
expiration getting enough not be effective other
phases. oxygen to the cells. and could signs/sympto
 Decreased Respiratory failure actually stress the ms of hypoxia
inspiratory may be correlated with ABGs
heart/respiratory
pressure. with variations in normal/accep
system,
respiratory rate, table range.
abdominal and potentially
thoracic pattern. lowering O₂
saturation,
especially if the
hyperventilation
is not simply
anxiety based)
Encourage slower To assist client in
respirations, use of “taking control”
pursed-lip technique of the situation
Maintain calm attitude
To limit level of
while dealing with patient
anxiety
Avoid overeating/gas
forming foods
May cause
abdominal
distention
ASSESSMENT DIAGNOSIS INFERENCE PLANING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired Gas After 4 hours of  Assess nutritional  Resulting in After 4 hours
Exchange r/t nursing interventions status including a loss of nursing
“Dyspnea and Visual Ventilation perfusion the patient will be serum albumin muscle interventions
Disturbances” as imbalance (altered able to Demonstrate level and body mass in the the patient
complained by the blood flow), alveolar- improved ventilation mass index . respiratory was be able to
patient capillary membrane and adequate muscles Demonstrate
changes (atelectasis) oxygenation of tissues which can improved
as evidenced by by ABGs within client’s  Evaluate pulse lead to ventilation
Objective:
profound dyspnea and normal limits and oximetry to respiratory and adequate
somnolence absence of symptoms determine failure. oxygenation
 Tachycardia. of respiratory distress. oxygenation; of tissues by
 Hypoxia. evaluate lung  To assess ABGs within
 Somnolence: volumes and for client’s
Lethargy. forced vital respiratory normal limits
capacity. insufficienc and absence
y. of symptoms
 Elevate head of of respiratory
bed/position distress.
client  Promotes
appropriately, optimal
provide airway chest
adjuncts and expansion
suction, as an
indicated. drainage of
secretions.
 Help the client eat  Having a
small frequent BMI less
meals and use than 21 has
dietary been
supplements as associated
necessary . with earlier
mortality in
patients
with COPD.

 Encourage  Helps limit

adequate rest and oxygen
limit activities to needs/cons
within client umption.
tolerance.
Promote
calm/restful
environment.