ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain Abruptio After 8 hours of Independent: • To measure After 8 hours of
“Bigla na lang related placenta nursing • Monitor amount the amount of nursing
sumakit ng to collection of is premature interventions, of bleeding by blood loss. interventions,
matindi ang tiyan blood between separation of the the weighing all • Changes in the
ko , kahit 22 uterine wall and normally patient will pads. location or patient was able
linggo palang placenta. implanted demonstrate • Investigate pain intensity are to
ang placenta in the use reports, noting not demonstrate use
ipinagbubuntis third trimester. of relaxation location, uncommon of
ko” (I’m 22 weeks There are two skills, duration, but may relaxation skills,
pregnant and I feel types of other methods intensity (0-10 reflect other methods to
a abruption to promote comfort
sharp pain in my scale), and developing
placentae; promote comfort characteristics complications.
abdomen) as
concealed (dull, sharp, • Early
verbalized by the
hemorrhage and constant). recognition of
patient.
external • Monitor possible
hemorrhage. maternal adverse
Objective:
With vital signs and effects allows
• Abdominal
a concealed fetal heart rate for prompt
guarding.
hemorrhage, the through intervention.
• Muscle placenta
tension. continuous • Fundal height
separation monitoring. may increase
• Irritability. centrally, and a • Measure and with
large amount of record fundal concealed
blood is height. bleeding.
accumulated • Position mother • To enhance
under the in the left lateral placental
placenta. When position, with the perfusion.
an external head of the bed • Promotes
hemorrhage is elevated. relaxation and
present, the
• Provide comfort may enhance
separation is
measure like patient’s
along the
back rubs, deep coping
placental breathing. abilities by
margin, Instruct in refocusing
and blood flows relaxation or attention.
under the visualization
membranes and exercises.
through cervix. Provide
Women at risk diversional
for activities.
developing
abruption Collaborative:
placentae • Administer
include • To supply
oxygen as
those with adequate
indicated.
history oxygen to the
of hypertension fetus and
or mother and
previous prevents
abruption further
placenta, complication.
abdominal
trauma
during
pregnancy,
anomaly of the
umbilical cord,
uterine fibroids,
advanced
maternal age,
cigarette
smoking, and
cocaine abuse.