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Assessment

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.

Monitor Vital Signs

To obtain baseline data

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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

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Provides information Assess hourly intake and output. about maternal and fetal physiologic compensation to blood loss

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Detecting increased in Assess abdomen for tenderness or rigidity- if present, measure abdomen at umbilicus measurement of abdominal girth suggests active abruption

Safe and quality nursing care

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

Safe and quality nursing care

Provide supplemental O2 as ordered via face mask or nasal cannula @ 10-12 L/min. Intervention increases available O2 to saturate decreased hemoglobin

Safe and quality nursing care

Initiate IV fluids as ordered (specify fluid type and rate). For replacement of fluid vol. loss

Collaboration and teamwork

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

Safe and quality nursing care

Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Core Competencies

Objective: Systolic=70-80 mmHg Pallor Bradycardia Patient unresponsive Active bleeding

Decreased cardiac output related to altered myocardial contractility

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

Safe and quality nursing care

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

Decreases oxygen consumption and risk of decompensation

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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

Objective: O2 sat=70-80% Apnea Hgb=10.7g/dl

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

Note customary baseline data (usual BP, weight, lab values)

For comparison with current findings

Safe and quality nursing care

Determine presence of dysrhythmias

To identify alterations from normal

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After 8 hours of effective nursing interventions, the patient will have a normal peripheral blood circulation. Check for Homans Sign Perform blanch test

To identify / determine adequate perfusion

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To determine presence of thrombus formation

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To lessen O2 demand Encourage quiet & restful environment To promote circulation Elevate HOB

Management of resources and environment

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Encourage use of relaxation

To decrease tension

Health education

techniques

level

Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Core Competencies

Subjective: The patient reported presence of pain

Acute Pain related to ischemia

After 30 minutes to 1 hour of effective nursing intervention, the patient will have reduced pain

Monitor vital signs

To provide baseline data of patient

Safe and quality nursing care

Provide comfort measures, quiet environment and calm activities

To promote non pharmacological pain management Management of resources and environment

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

Administer analgesics as prescribed Assessment Nursing Diagnosis Planning Intervention

To alleviate pain

Collaboration and teamwork

Rationale

Core Competencies

Objective: Systolic=70-80 mmHg Pallor Bradycardia Low blood pressure Patient unresponsive Active bleeding

Risk for fall related to decreased blood pressure

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

monitor vital signs

to have a baseline data

Safe and quality nursing care

keep the side rails of the bed raised

to protect from falling out of bed

Health education

remind client to walk slowly, rest

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

Objective: O2 sat=70-80% apnea

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. Assess skin color for development of cyanosis, especially circumoral cyanosis.

4. Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia.

Safe and quality nursing care

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.

Safe and quality nursing care

Safe and quality nursing care

mask.

6. Promotes better lung expansion and improved gas exchange. Safe and quality nursing care

6. Position patient with head of bed 45 degrees (if tolerated).

7. Promotes alveolar expansion and prevents alveolar collapse. Splinting helps

7. Assist patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes,

reduce pain and optimizes deep breathing and coughing efforts.

8. Even simple activities, such as bathing, can

splinting of the chest).

increase oxygen consumption and cause fatigue.

8. Pace activities and provide rest periods to prevent fatigue.

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