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Nursing Diagnosis
Planning
Intervention
Rationale
Core Competencies
Objective: Systolic=70-80 mmHg Pallor Bradycardia Patient unresponsive Active bleeding Patient has placenta previa in pregnancy
Deficient Fluid Volume related to Active Blood Loss Secondary to Disrupted Placental Implantation
Short Term: After 4 hours of NI, the pt will verbalize understanding of causative factors. Long Term: After 4 days of NI, the pt will maintain fluid volume at a functional level AEB individually adequate urinary output and stable vital signs.
Assess color, odor, consistency and amount of vaginal bleeding; weigh pads
Provides information about active bleeding versus old blood, tissue loss and degree of blood loss
Provides information Assess hourly intake and output. about maternal and fetal physiologic compensation to blood loss
Detecting increased in Assess abdomen for tenderness or rigidity- if present, measure abdomen at umbilicus measurement of abdominal girth suggests active abruption
Assess SaO2, skin color, temp, moisture, turgor, capillary refill (specify frequency) Assessment provides information about blood vol., O2 saturation and peripheral perfusion
Provide supplemental O2 as ordered via face mask or nasal cannula @ 10-12 L/min. Intervention increases available O2 to saturate decreased hemoglobin
Initiate IV fluids as ordered (specify fluid type and rate). For replacement of fluid vol. loss
Position Pt. in supine with hips elevated if ordered or left lateral position. Position decreases pressure on placenta and cervical os. Left lateral position improves placental perfusion
Assessment
Nursing Diagnosis
Planning
Intervention
Rationale
Core Competencies
After 4 hours of effective nursing intervention, the patient will demonstrate decreased episodes of dyspnea and dysrhythmias.
Evaluate client reports and evidence of extreme fatigue, intolerance for activity, sudden or progressive weight gain, swelling of extremities and progressive shortness of breath Monitor vital signs
To assess for signs of poor ventricular function and pending cardiac failure
Provides baseline for comparison to follow trends and evaluate response to interventions Safe and quality nursing care
After 12 hours of effective nursing intervention, the patient display hemodynamic stability Keep client on bed or chair rest in position of comfort. May raise legs to 20
to 30 degrees in shock situation To note effectiveness of medications Monitor cardiac rhythm continuously To reduce anxiety Encourage relaxation techniques Health education Safe and quality nursing care
Assessment
Nursing Diagnosis
Planning
Intervention
Rationale
Core Competencies
Ineffective tissue perfusion related to decreased HgB concentration in blood & hypovolemia Secondary to placenta previa
After 4 hours of effective nursing intervention, the patient will demonstrate increased tissue perfusion
After 8 hours of effective nursing interventions, the patient will have a normal peripheral blood circulation. Check for Homans Sign Perform blanch test
To lessen O2 demand Encourage quiet & restful environment To promote circulation Elevate HOB
To decrease tension
Health education
techniques
level
Assessment
Nursing Diagnosis
Planning
Intervention
Rationale
Core Competencies
After 30 minutes to 1 hour of effective nursing intervention, the patient will have reduced pain
After 2 hours of effective nursing interventions, the patients pain will be alleviated Encourage use of relaxation techniques such as focused breathing Encourage diversional activities. To distract attention and reduce tension Health education To distract attention and reduce tension Health education
To alleviate pain
Rationale
Core Competencies
Objective: Systolic=70-80 mmHg Pallor Bradycardia Low blood pressure Patient unresponsive Active bleeding
After 4 hours of effective nursing intervention, the patient will have a modified environment as indicated to enhance safety
establish rapport
to promote cooperation
Communication
Health education
to prevent injury
Health education
After 8 hours of effective nursing interventions, the patient will be free of injury
adequately between intervals of walking use effective lighting for continuous inform pts so not to leave her in the bathroom monitoring and guidance to the client Health education
Assessment
Nursing Diagnosis
Planning
Intervention
Rationale
Core Competencies
Impaired Gas exchange related to decreased pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus and vasoconstriction
Short Term: After 4 hours of effective nursing interventions, the patient will have an improved breathing pattern. 2. Assess for changes in orientation and behavior. Long Term: After 8 hours of effective nursing interventions, patient will demonstrate a normal depth, rate and pattern of respirations. 3. Place the patient on continuous pulse oximetry. 3. Pulse oximetry is useful in detecting changes in oxygenation. Oxyge n saturation should be maintained at Safe and quality nursing care 2. Restlessness is an early sign of hypoxia. Mentation gets worse as hypoxia increases due to lack of blood supply to the brain. Safe and quality nursing care 1. Monitor vital signs 1. To note any deviation that may indicate further progression of illness Safe and quality nursing care Safe and quality nursing care
90% or greater.
4. Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia.
5. Early supplemental oxygen is essential in all trauma patients since early mortality is 5. Provide supplemental oxygen, via 100% O2 nonrebreather associated with inadequate delivery of oxygenated blood to the brain and vital organs.
mask.
6. Promotes better lung expansion and improved gas exchange. Safe and quality nursing care
7. Assist patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes,