Tag Archive for: Placenta Previa Nursing Care Plan Revised

Assessment Data

(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)

Goals & Outcome

(Two statements are required for each nursing diagnosis.  Must be Patient and/or family focused; measurable; time-specific; and reasonable.)

Nursing Interventions

(List at least three nursing or collaborative interventions with rationale for each goal & outcome.)

Rationale

(Provide reason why intervention is indicated/therapeutic; provide references.)

(Was goal met?  How would you revise the plan of care according to the patient’s response to current plan ?)

1. Patient reports blood clots on her innerwear and on the toilet bowl over the past one week.

1. Patient reports noticing severe vaginal bleeding as she was using the bathroom in the morning she was transported to the hospital

1. Patient reports feeling weak, diminished vision, and headache before being transported by an ambulance to the hospital.

The patient will maintain an appropriate fluid volume, determined by assessing urinary output and stability of vital signs

Statement #2

The patient will stop bleeding and display homeostasis.

Statement #1

The patient will engage and indicate activities and activity level that lower heart workload.

Statement #2

The patient will achieve a hemodynamic stability.

1. Assess blood color, odor and amount and vaginal bleeding consistency.

1. Evaluate and monitor vital signs.

1. Examine intake and output every hour.

1. Monitor vital signs, particularly blood pressure.

1. Monitor and closely observe the patient usual consciousness levels.

1. Observe intake and output

1. Placenta Previa is associated with painless, bright red, sudden, and abrupt bleeding (Anderson-Bagga & Sze, 2019).

1. It is critical to monitor vitals to determine risk of hypovolemic shock (Vera, 2022).

1. Monitoring urine output helps determine whether the patient has adequate blood volume to perfuse the kidneys (Vera, 2022).

1. Monitoring blood pressure is fundamental to determine development of systemic vascular resistance (Trammel & Sapra, 2020).

1. Diminished cardiac output can cause confusion, restlessness, and/or disorientation (Vera, 2022).

1. Monitoring input and output allows the determination that kidneys are functioning properly or not (Vera, 2022).

The desired outcome was achieved as the patient managed to maintain appropriate fluid volume, shown by the normal urinary output and steady vital signs. The patient stopped bleeding, displaying homeostasis.

Outcome #2

The expected outcome was achieved as the patient demonstrated activities that lower heart workload. The patient also achieved hemodynamic stability.