Assessment Diagnosis Scientific explanation Planning Intervention Rationale Evaluation

S=ØO= Changes in fetal heart rate or activity

Release of meconium

Slight change in vital signs except for the BP

Impaired fetal gas exchange r/t altered blood flow and decreased surface area of gas exchange at the site of placental detachment.

Placenta previa is the development of placenta in the lower uterine segment partially or completely covering the internal cervical os. The cause is unknown but a possible theory states that the embryo will implant in the lower uterine segment if the deciduas in the uterine fundus is not favorable. Complications are immediate hemorrhage, shock and maternal death; fetal mortality and post partum hemorrhage.

After hours of nursing interventions, the pt. will verbalize understanding of causative factors and appropriate interventions.

Assess vital signs q 15 minutes

Maintain bed rest or chair rest when indicated. Provide frequent rest periods and uninterrupted night time sleep.

Monitor amt. and type of bleeding.

Position the mother on her left side.

Restrict vaginal examination.

Monitor fetal contractions and fetal heart rate by external monitor.

.

Monitor positive attitude about fetal outcome.

Administer oxygen as indicated

Provides baseline data on the maternal blood loss

Systemic rest is mandatory and important throughout al phases of dse. to reduce fatigue, and improve strength.

Provide objective evidence o bleeding.

To promote placental perfusion.

Prevents tearing of placenta if placenta previa is the cause of bleeding.

Assess whether labor is present and fetal status and external system avoids cervical trauma.

Support mother and child bonding.

Provides adequate fetal oxygenation despite of lowered maternal circulating volume.

After hours of nursing interventions, the patient was able to verbalize understanding of causative factors and appropriate interventions.

Assessment Diagnosis Scientific explanation Outcomes Nursing Intervention Rationale Evaluation

S- Ø

O-Bleeding Episodes (amount, duration)Facial Grimace due of Pain or no complaint of painAbdomen soft/hard when palpatedManifest Body WeaknessLow BPIncreased HRDecreased RRFetal HR >120-160 bpmDecreased Urine OutIncreased Urine ConcentrationPale, Cool SkinIncreased Capillary Refill (specify)Lab. Results

Fluid Volume Deficient r/t Active Blood Loss Secondary to Disrupted Placental Implantation

Fluid volume deficient is a state in which an individual is experiencing decreased intravascular, interstitial and/or intracellular fluid. Active Blood Loss or Hemorrhage due to disrupted placental implantation during pregnancy may manifest signs and symptoms of fluid vol. deficient that may later lead to hypovolemic shock and cause maternal and fetal death.

After hours of nursing intervention and medical assistance, Pt.will exhibit signs of adequate fluid balance during pregnancy.

Assess color, odor, consistency and amount of vaginal bleeding; weigh pads

Assess hourly intake and output.

Assess baseline data and note changes. Monitor FHR.

Assess abdomen for tenderness or rigidity- if present, measure abdomen at umbilicus (specify time interval)

Assess SaO2, skin color, temp, moisture, turgor, capillary refill (specify frequency)

Assess for changes in LOC: note for complaints of thirst or apprehension

Provide supplemental O2 as ordered via facemask or nasal cannula @ 10-12 L/min.

Initiate IV fluids as ordered (specify fluid type and rate).

Position Pt. in supine with hips elevated if ordered or left lateral position.

Monitor lab. Work as obtained: Hgb & Hct, Rh and type, cross match for 2 units RBCs, urinalysis, etc. Scheduled for ultrasound as ordered.

Determine if Pt. has any objections to blood transfusions- inform physician.

Administer blood transfusion as ordered with client consent.

Monitor closely for transfusions reaction

Provides information about active bleeding versus old blood, tissue loss and degree of blood loss

Provides information about maternal and fetal physiologic compensation to blood loss

Assessment provides information about possible infection, placenta previa or abruption. Warm, moist, bloody environment is ideal for growth of microorganisms.

Detecting increased in measurement of abdominal girth suggests active abruption

Assessment provides information about blood vol., O2 saturation and peripheral perfusion

To detect signs of cerebral perfusion

Intervention increases available O2 to saturate decreased hemoglobin

For replacement of fluid vol. loss

Position decreases pressure on placenta and cervical os. Left lateral position improves placental perfusion

Lab. Work provides information about degree of blood loss; prepares for possible

Pt. has no further vaginal bleeding; Blood pressure is maintained at at least 100/60 mm Hg; PR <100 bpm; fetal HR is maintained at 120-160 bpm; UO >30ml/hr.

Provide emotional support; keep Pt. and family informed of findings and continuing plan of care.

Administered prenatal vitamins and iron as ordered: provide a diet high in iron: lean meats, dark green leafy vegetables, eggs, and whole grains.

Prepare Pt. for cesarean birth if ordered when severe hemorrhage, abruption, complete previa at term is already experience.

transfusion. Ultra sound provides info about the cause of bleeding

Pt. may have religious beliefs related to accepting blood products

To provides replacement of blood components and volume

To prevent for Potentially life-threatening allergic reaction may result from incompatible blood

Support and information decrease anxiety and help Pt. and family to anticipate what might happen next.

Proper diet and vitamins replace nutrient losses from active bleeding to prevent anemia- iron is a necessary component of hemoglobin

Cesarean Birth may be necessary to resolve the hemorrhage or prevent fetal or maternal injury.

Assessment Diagnosis Scientific explanation Planning Intervention rationale evaluation

S- ØO-Elevated BP, P, R Insomnia

Restlessnes

Dry mouth

Dilated pupils

Frequent urination

Diarrhea

Patient complains of apprehension, nervousness, tension

Inability to concentrate

Shaking

Anxiety Vague uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat.

After hours of nursing intervention the pt. will Demonstrate a decrease in anxiety A.E.B. reduction in presenting physiological, emotional, and/or cognitive manifestations of anxiety; and verbalization of relief of anxiety.

Establish rapport. Provide reassurance and comfort.

Monitor vital signs.

Observe the clients behavior. Note any unusual activities.

Review results of diagnostic test.

Be aware of defense mechanisms that the pt. manifests.

Review coping skills that was used in the past.

Provide accurate information about placenta previa.

List available resources or persons, including hotlines or crisis managers.

Review strategies, such as role playing, use of visualizations to practice anticipated events.

Administer anti-anxiety drugs/sedatives, as ordered.

Review medications regimen and possible interactions, especially with OTC drugs/alcohol, and so forth. Discuss appropriate drug substitutions, changes in dosage or time of dose.

To gain the trust and cooperation of the patient.

Identify physical responses associated with both medical and emotional conditions.

This can point to the clients level of anxiety.

This may point to physiological source of anxiety.

It may interfere with ability to deal with problem.

To determine those that might be helpful in the current circumstance.

Helps client to identify what is reality based.

To provide ongoing and timely support.

Useful for being prepared in dealing with anxiety provoking situation.

Helps to manage the pt. experiencing anxiety.

Helps minimize side effects of drugs that may aggravate the condition.

After hours of nursing intervention the manifested decreased anxiety AEB reduced presenting manifestations of anxiety and the pt. was able to verbalize a relief from anxiety.

Assessment Nursing diagnosis

Scientific explanation Planning Intervention Rationale Evaluation

S-ØO-Weakness or fatigue

Exertional discomfort or dyspnea

Abnormal heart rate or blood pressure in response to activity

Electrocardiographic changes reflecting arrythmias or ischemia

Activity Intolerance r/t Enforced Bed Rest During Pregnancy Secondary to Potential for Hemorrhage

Insufficient physiological or psychological energy to endure or complete required or desired daily activity.

After hours of nursing intervention the pt. will demonstrate a decrease in physiological signs of intolerance AEB normal range of pt.’s vital signs.

Evaluate actual and perceived limitations of deficient in light of unusual status.

Monitor vital or cognitive signs, watch for changes of blood pressure, heart and respiratory rate; note skin pallor and cyanosis and the presence of confusion.

Adjust activities. Reduce intensity level of activity or discontinue activities that cause undesired physiological changes.

Increase exercise levels gradually, such as stopping to rest for 3 mins. during a 10-minute walk or sitting down to brush hair instead of standing.

Provide positive atmosphere while acknowledging difficulty of the situation of the client.

Assist with activities and provide clients’ use of assistive devices.

Promote comfort measures and provide relief of pain.

Provide to other disciplines, such as O/PT, exercise physiologist or psychological counseling.

Give client information that provides evidence of daily progress.

Provide/monitor response to supplemental oxygen and medications and changes in treatment regimen.

Provides comparative baseline and provides information about needed interventions regarding quality of life.

Provides baseline data to detect the changes due to intolerance.

Prevents the pt.’s overexertion.

Preserves conservation of energy.

Helps minimize frustration and rechannel energy.

Protects the client from injury.

Gives the chance for the client to enhance ability to participate in activities.

To develop individually appropriate therapeutic regimens.

Sustains clients motivation.

Assess if the client is responding to the tx.

After hours of nursing intervention the Pt.’s vital signs have returned to normal range and manifested decreased physiological signs of activity intolerance.

Assessment Nursing diagnosis

Scientific explanation Planning Interventions Rationale Evaluation

S-Ø

O-Diminished productivity

Increased alertness

Increased pulse; vomiting; diarrhea; muscle tightness

Increased RR; dyspnea

Increased BP; pallor

Increased perspiration and pupil dilation.

Fear r/t Threat to Maternal and Fetal Survival Secondary to Excessive Blood Loss

Response to perceived threat that is consciously recognized as danger.

After hours of nursing interventions the pt. will display appropriate range of feelings and lessened fear.

Ascertain clients’s perception of what is occurring and how it affects life.

Identify sensory deficits that may be present, such as vision/hearing impairment.

Stay with the client or make arrangements to have someone else be there.

Acknowledge normalcy of fear, pain, despair, and give “permission” to express feelings appropriately.

Modify procedures, if possible.

Promote client control, where possible, and help client identify and accept those things over which control is not possible.

Explain procedures within the level of client’s understanding and handle.

Review use of antianxiety medications and reinforce as prescribed.

Fear is a defensive mechanism in protecting oneself but, if left unchecked, can become disabling to the client’s life.

Identify if this affects sensory reception and interpretation of the environment.

Providing client with usual/desired support persons can diminish feelings of fear.

Promotes attitude of caring, opens door for discussion about feelings and/or addressing reality of situation.

Limits degree of stress, avoids overwhelming the fearful individual.

Strengthens internal locus of control.

Prevents confusion or overload of information.

To check for correct treatment and to assess efficiency of tx.

Post-operative NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME

Subjective:“Sobrang sakit,” as verbalized by the patient.

Objective:-Pain scale= 8/10-Teary eyed-(+) guarding behavior-(+) facial grimace-Irritable -Pale palpebral conjunctiva-Skin warm to touch-V/S taken asfollows:BP= 110/80PR= 80RR= 22T= 37.6

Acute pain r/t disruption of skin and tissue secondary to cesarean section.

STG: After 1-2hr of nursing intervention, patient will verbalize decrease intensity of pain from 8/10 to 3/10.

Independent:

- Established rapport.

- Monitored vital signs.

- Assessed quality, characteristics, severity of pain.

- Provided comfortable environment – changed bed linens and turned on the fan.

- Instructed to put pillow on the abdomen when coughing or moving.

- Instructed patient to do deep breathing and coughing exercise.

- Provided diversionary activities. Initiate ankle pumping, active lower extremity ROM, and walking

Collaborative:- Administer analgesic as per

doctor’s order.

-To have a good nurse-client relationship

-To establish a baseline data

-To establish baseline data for comparison in making evaluation and to assess for possible internal bleeding.

-Calm environment helps to decrease the anxiety of the patient and promote likelihood of decreasing pain.

- To check for diastasis recti and protect the area of the incision to improve comfort. And to initiate nonstressful muscle-setting techniques and progress as tolerated, based on the degree of separation.

- For pulmonary ventilation, especially when exercising, and to relieve stress and promote relaxation.

- To promote circulation, prevent venous stasis, prevent pressure on the operative site.

-Relieves pain felt by the patient

Goal met. After 2hrs of nursing intervention, the patient verbalized pain decreased from a scale of 8/10 – 3/20 as evidenced by (-) facial grimace (-) guarding behavior.Frequent small talks with significant others

ASSESSMENT DIAGNOSIS NURSING ANALYSIS

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:- none

Objective:- dressing dry and intact-V/S taken asfollows:T: 37.3P: 80R: 19BP: 120/80

Risk for infection related inadequate primary defenses secondary to surgical incision

Due to an elective cesarean section, patient’s skin and tissue were mechanically interrupted. Thus, the wound is at risk of developing infection.

STG:After 4 hours of nursing intervention, patient will be able to understand causative factors, identify signs of infection and report them to health care provider accordingly.

LTG:

Independent-Monitor vital signs

-Inspect dressing and perform wound care

- Monitor white blood count (WB

- Monitor Elevated

-To establish a baseline data

-Moist from drainage can be a source of infection

- Rising WBC indicates body’s efforts to combat pathogens; normal values: 4000 to 11,000 mm3

Patient is expected to be free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.

After 2-3 days of nursing intervention, patient will achieve timely wound healing, be free of purulent drainage or erythema, be afebrile and be free of infection.

temperature, Redness, swelling, increased pain, or purulent drainage at incisions

- Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient.

- Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated).

- Encourage coughing and deep breathing; consider use of incentive spirometer.

Independent:- Administer

antibiotics

-these are signs of infection

-Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another

- Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI).

- These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia.

-Antibiotics have bactericidal effect that combats pathogens

ASSESSMENTNURSING

DIAGNOSISPLANNING INTERVENTIONS RATIONALE EVALUATION

Objective Cues: Patient

has not yet eliminated since delivery

Absence of bruit sounds

Normal pattern of bowel has not yet returned

Risk for constipation r/t post pregnancy 2° cesarean section

Short Term Goal:

Within 8º of nursing interventions, the patient will be able to demonstrate behaviors or lifestyle changes to prevent developing problem

Long Term Goal:

Within 3 days of nursing interventions, the patient will be able to maintain usual pattern of bowel functioning

INDEPENDENT INTERVENTIONS:

Ascertain normal bowel functioning of the patient, about how many times a day does she defecate

Encourage intake of foods rich in fiber such as fruits

Promote adequate fluid intake. Suggest drinking of warm fluids, especially in the morning to stimulate peristalsis

Encourage ambulation such as walking within individual limits

This is to determine the normal bowel pattern

To increase the bulk of the stool and facilitate the passage through the colon

To promote moist soft stool

After 8º of nursing interventions, the patient was able to identify measures to prevent infection as manifested by client’s verbalization of: “Iinom ako ng maraming tubig at kakain ng prutas para makadumi ako.”

However, since she has had cesarean, also encourage adequate rest periods

COLLABORATIVE:

Administer bulk-forming agents or stool softeners such as laxatives as indicated or prescribed by the physician

To stimulate contractions of the intestines and prevent post operative complications

To avoid stress on the cesarean incision/ wound

To promote defecation