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NCP Vaginal Bleeding

The patient was experiencing vaginal bleeding at 37 weeks gestation likely due to abruptio placentae. The nurse's assessment found the patient's vital signs were elevated and she was at risk for shock due to blood loss. The nursing plan was to monitor the patient closely for 8 hours, assist with bleeding and provide comfort measures to promote relaxation. After 8 hours of nursing interventions, the patient was able to demonstrate relaxation techniques and her vital signs had stabilized, indicating the interventions were effective.

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384 views2 pages

NCP Vaginal Bleeding

The patient was experiencing vaginal bleeding at 37 weeks gestation likely due to abruptio placentae. The nurse's assessment found the patient's vital signs were elevated and she was at risk for shock due to blood loss. The nursing plan was to monitor the patient closely for 8 hours, assist with bleeding and provide comfort measures to promote relaxation. After 8 hours of nursing interventions, the patient was able to demonstrate relaxation techniques and her vital signs had stabilized, indicating the interventions were effective.

Uploaded by

jayye.aronce
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BASIS
Vaginal Fluid Volume The premature Within 8 Independent: After 8 hours of nursing
Bleeding Deficit separation of hours of care •Monitor the •Monitoring helps interventions, the patient
related to the placenta the client, the client’s vital signs the nurse to identify was able to demonstrate
Objective bleeding from the uterus patient was and fetal heart the development of use of relaxation skills,
Data: is known as able to monitoring. client’s vital signs. other methods to promote
BP- 160/100 Risk for abruptio demonstrate comfort and prevent
hhmg shock placentae, also use of bleeding.
PR- 89 Bpm related to known as relaxation • Assist and •Excessive bleeding
RR- 20 Rpm separation of placental skills such as monitor vaginal may result in shock.
SPO2- 98% placenta as abruptio, deep bleeding. Amount of obvious
T- 37.5 evidence by typically exhibit breathing blood may not fully
abdominal bleeding, exercise and indicate severity due
pain and uterine proper to possible internal
bleeding. contractions, positioning bleeding.
and fetal promote • Start input and •To monitor
distress. comfort. output monitoring. circulatory blood
Placental volume. To ensures
abruption, a that the mother has
major cause of adequete oral
third trimester hydration or if there
bleeding is a need to
associated with commence IV
fetal and hydration therapy.
maternal
morbidity and •Position mother • To enhance
mortality in the left lateral placental perfusion.
should be position, with the
considered head of the bed
whenever elevated.
bleeding occurs • Provide comfort • Promotes
in the second measure like back relaxation and may
half of rubs, deep enhance patient’s
pregnancy. breathing. Instruct coping abilities by
in relaxation or refocusing.
visualization
exercise

Collaborative:
Administer oxygen To Supply adequate
as indicated and oxygen to the fetus
medication and mother and
oxytocin. preventing preterm
birth.

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