Scientific

Assessment Diagnosis Planning Intervention Rationale Evaluation

explanation
S=Ø Impaired fetal Placenta After hours of Assess vital Provides After hours of
O= gas exchange previa is the nursing signs q 15 baseline data nursing
Changes in r/t altered development interventions, minutes on the interventions,
fetal heart blood flow and of placenta in the pt. will maternal the patient
rate or activity decreased the lower verbalize blood loss was able to
surface area of uterine understanding Maintain bed verbalize
Release of gas exchange segment of causative rest or chair Systemic rest understanding
meconium at the site of partially or factors and rest when is mandatory of causative
placental completely appropriate indicated. and important factors and
Slight change detachment. covering the interventions. Provide throughout al appropriate
in vital signs internal frequent rest phases of dse. interventions.
except for the cervical os. periods and to reduce
BP The cause is uninterrupted fatigue, and
unknown but a night time improve
possible sleep. strength.
theory states
that the Monitor amt. Provide
embryo will and type of objective
implant in the bleeding. evidence o
lower uterine bleeding.
segment if the Position the
deciduas in mother on her To promote
the uterine left side. placental
fundus is not perfusion.
favorable. Restrict
Complications vaginal Prevents
are immediate examination. tearing of
hemorrhage, placenta if
shock and placenta
maternal previa is the
death; fetal cause of
mortality and Monitor fetal bleeding.
post partum contractions
hemorrhage. and fetal heart
rate by Assess
external whether labor
monitor. is present and
fetal status
. and external
system avoids
Monitor cervical
positive trauma.
attitude about
fetal outcome. Support
mother and
child bonding.
Administer
oxygen as
indicated
Provides
adequate fetal
oxygenation
despite of
lowered
maternal
circulating
volume.
 Diagnosi Scientific Outcome Nursing
Assessment Rationale Evaluation
s explanation s Intervention
S- Ø Fluid Fluid volume After Assess color, odor, Provides information Pt. has no further
Volume deficient is a hours of consistency and about active vaginal bleeding;
O- Deficient state in which nursing amount of vaginal bleeding versus old Blood pressure is
Bleeding r/t Active an individual intervent bleeding; weigh blood, tissue loss maintained at at
Episodes Blood is ion and pads and degree of blood least 100/60 mm Hg;
(amount, Loss experiencing medical loss PR <100 bpm; fetal
duration) Secondar decreased assistanc HR is maintained at
Facial y to intravascular, e, Pt. Assess hourly 120-160 bpm; UO
Grimace Disrupte interstitial will intake and output. Provides information >30ml/hr.
due of Pain d and/or exhibit about maternal and
or no Placental intracellular signs of fetal physiologic
complaint Implanta fluid. Active adequat compensation to
of pain tion Blood Loss or e fluid Assess baseline blood loss
Abdomen Hemorrhage balance data and note
soft/hard due to during changes. Monitor Assessment
when disrupted pregnanc FHR. provides information
palpated placental y. about possible
Manifest implantation infection, placenta
Body during previa or abruption.
Weakness pregnancy Warm, moist, bloody
Low BP may manifest environment is ideal
Increased signs and Assess abdomen for growth of
HR symptoms of for tenderness or microorganisms.
Decreased fluid vol. rigidity- if present,
RR deficient that measure abdomen Detecting increased
Fetal HR may later at umbilicus in measurement of
>120-160 lead to (specify time abdominal girth
bpm hypovolemic interval) suggests active
Decreased shock and abruption
Urine Out cause Assess SaO2, skin
Increased maternal and color, temp,
Urine fetal death. moisture, turgor, Assessment
Concentrati capillary refill provides information
on (specify frequency) about blood vol., O2
Pale, Cool saturation and
Skin Assess for changes peripheral perfusion
Increased in LOC: note for
Capillary complaints of To detect signs of
Refill thirst or cerebral perfusion
(specify) apprehension
Lab. Results

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

Initiate IV fluids as For replacement of

ordered (specify fluid vol. loss
fluid type and
rate).

Position decreases
Position Pt. in pressure on
supine with hips placenta and
elevated if ordered cervical os. Left
or left lateral lateral position
position. improves placental
perfusion

Monitor lab. Work Lab. Work provides

as obtained: Hgb & information about
Hct, Rh and type, degree of blood loss;
cross match for 2 prepares for
units RBCs, possible transfusion.
urinalysis, etc. Ultra sound provides
Scheduled for info about the cause
ultrasound as of bleeding
ordered.
Pt. may have
Determine if Pt. religious beliefs
has any objections related to accepting
to blood blood products
transfusions-
inform physician.

To provides
Administer blood replacement of
transfusion as blood components
ordered with client and volume
consent.
To prevent for
Monitor closely for Potentially life-
transfusions threatening allergic
reaction reaction may result
from incompatible
blood

Provide emotional Support and

support; keep Pt. information
and family decrease anxiety
informed of and help Pt. and
findings and family to anticipate
continuing plan of what might happen
care. next.

Administered
prenatal vitamins Proper diet and
and iron as vitamins replace
ordered: provide a nutrient losses from
diet high in iron: active bleeding to
lean meats, dark prevent anemia-
green leafy iron is a necessary
vegetables, eggs, component of
and whole grains. hemoglobin

Prepare Pt. for

cesarean birth if
ordered when Cesarean Birth may
severe be necessary to
hemorrhage, resolve the
abruption, hemorrhage or
complete previa at prevent fetal or
term is already maternal injury.
experience.
 Scientific
Assessment Diagnosis Planning Intervention rationale evaluation
explanation
S- Ø Anxiety Vague uneasy After hours of Establish To gain the After hours of
O- feeling of nursing rapport. trust and nursing
Elevated BP, P, discomfort or intervention Provide cooperation of intervention
R dread the pt. will reassurance the patient. the manifested
Insomnia accompanied Demonstrate a and comfort. decreased
by an decrease in Identify anxiety AEB
Restlessnes autonomic anxiety A.E.B. Monitor vital physical reduced
response; a reduction in signs. responses presenting
Dry mouth feeling of presenting associated manifestations
apprehension physiological, with both of anxiety and
Dilated pupils caused by emotional, medical and the pt. was
anticipation of and/or emotional able to
Frequent danger. It is an cognitive conditions. verbalize a
urination altering signal manifestations relief from
that warns of of anxiety; and anxiety.
Diarrhea impending verbalization Observe the
danger and of relief of clients This can point
Patient enables the anxiety. behavior. Note to the clients
complains of individual to any unusual level of
apprehension, take measures activities. anxiety.
nervousness, to deal with
tension threat.
This may point
Inability to to
Review results
concentrate physiological
of diagnostic
source of
test.
Shaking anxiety.

Be aware of It may
defense interfere with
mechanisms ability to deal
that the pt. with problem.
manifests. To determine
those that
Review coping might be
skills that was helpful in the
used in the current
past. circumstance.

Provide Helps client to

accurate identify what
information is reality
about placenta based.
previa.
To provide
ongoing and
List available
timely
resources or
support.
persons,
including
hotlines or
crisis
managers.
Useful for
being
Review
prepared in
strategies,
dealing with
such as role
anxiety
playing, use of
provoking
visualizations
situation.
to practice
anticipated
events.
Helps to
manage the
Administer pt.
anti-anxiety experiencing
drugs/sedative anxiety.
s, as ordered.

Review Helps
medications minimize side
regimen and effects of
possible drugs that
interactions, may
especially with aggravate the
OTC condition.
drugs/alcohol,
and so forth.
Discuss
appropriate
drug
substitutions,
changes in
dosage or time
of dose.
 Nursing Scientific
Assessment Planning Intervention Rationale Evaluation
diagnosis explanation
S-Ø Activity Insufficient After hours of Evaluate Provides After hours of
O- Intolerance r/t physiological nursing actual and comparative nursing
Weakness or Enforced Bed or intervention perceived baseline and intervention
fatigue Rest During psychological the pt. will limitations of provides the Pt.’s vital
Pregnancy energy to demonstrate a deficient in information signs have
Exertional Secondary to endure or decrease in light of about needed returned to
discomfort or Potential for complete physiological unusual status. interventions normal range
dyspnea Hemorrhage required or signs of regarding and
desired daily intolerance quality of life. manifested
Abnormal activity. AEB normal decreased
heart rate or range of pt.’s Provides physiological
blood pressure vital signs. Monitor vital or baseline data signs of
in response to cognitive to detect the activity
activity signs, watch changes due to intolerance.
for changes of intolerance.
Electrocardiogr blood pressure,
aphic changes heart and
reflecting respiratory
arrythmias or rate; note skin
ischemia pallor and
cyanosis and
the presence Prevents the
of confusion. pt.’s
overexertion.
Adjust
activities.
Reduce
intensity level
of activity or
discontinue
activities that Preserves
cause conservation of
undesired energy.
physiological
changes.

Increase
exercise levels
gradually, such
as stopping to
rest for 3 mins. Helps minimize
during a 10- frustration and
minute walk or rechannel
sitting down to energy.
brush hair
instead of
standing.
Protects the
client from
Provide injury.
positive
atmosphere
while
acknowledging Gives the
difficulty of the chance for the
situation of the client to
client. enhance ability
to participate
Assist with in activities.
activities and
provide clients’ To develop
use of assistive individually
devices. appropriate
therapeutic
Promote regimens.
comfort
measures and
provide relief Sustains
of pain. clients
motivation.
Provide to
other
disciplines, Assess if the
such as O/PT, client is
exercise responding to
physiologist or the tx.
psychological
counseling.

Give client
information
that provides
evidence of
daily progress.

Provide/monito
r response to
supplemental
oxygen and
medications
and changes in
treatment
regimen.
 Nursing Scientific
Assessment Planning Interventions Rationale Evaluation
diagnosis explanation
S-Ø Fear r/t Threat Response to After hours of Ascertain Fear is a
to Maternal perceived nursing clients’s defensive
O- and Fetal threat that is interventions perception of mechanism in
Diminished Survival consciously the pt. will what is protecting
productivity Secondary to recognized as display occurring and oneself but, if
Excessive danger. appropriate how it affects left unchecked,
Increased Blood Loss range of life. can become
alertness feelings and disabling to
lessened fear. the client’s life.
Increased
pulse; Identify if this
vomiting; Identify affects sensory
diarrhea; sensory reception and
muscle deficits that interpretation
tightness may be of the
present, such environment.
Increased RR; as
dyspnea vision/hearing
impairment. Providing client
Increased BP; with
pallor Stay with the usual/desired
client or make support
Increased arrangements persons can
perspiration to have diminish
and pupil someone else feelings of fear.
dilation. be there.
Promotes
Acknowledge attitude of
normalcy of caring, opens
fear, pain, door for
despair, and discussion
give about feelings
“permission” and/or
to express addressing
feelings reality of
appropriately. situation.

Modify Limits degree

procedures, if of stress,
possible. avoids
overwhelming
the fearful
individual.
Promote client
control, where Strengthens
possible, and internal locus
help client of control.
identify and
accept those
things over
which control
is not possible.

Explain Prevents
procedures confusion or
within the level overload of
of client’s information.
understanding
and handle.

Review use of To check for

antianxiety correct
medications treatment and
and reinforce to assess
as prescribed. efficiency of tx.