Abruptio placenta, also called placental abruption, is where the placenta separa

Abruptio placenta, also called placental abruption, is where the placenta separates from the uterine wall prematurely, usually after the 20th week of gestation, producing hemorrhage. It is a common cause of bleeding during the second half of pregnancy. Firm diagnosis, in the presence of heavy maternal bleeding, may indicate termination of pregnancy. Fetal prognosis depends on the gestational age and amount of blood lost; maternal prognosis is good if hemorrhage can be controlled.
Nursing Care Plans
Nurses play a vital role in preventing complications for patients with abruptio placentae. Accurate assessment and prompt intervention will promote a safe delivery of the newborn. Here are three (3) nursing care plans for patients with abruptio placentae.
1. Ineffective Tissue Perfusion
Related to:
Excessive blood loss
Possibly evidenced by:
Loss of blood
FHR pattern
Altered BP compared to baseline
Altered PR Severe abdominal pain and rigidity
Pallor
Changes in LOC
Decrease urine output
Edema
Delay in wound healing
Positive Homan’s sign
Skin temperature changes
Desired outcome:
Nursing InterventionsRationale
Assess patient’s vital signs, O2 saturation, and skin color.For baseline data.
Monitor for restlessness, anxiety, hunger and changes in LOCThese conditions may indicate decreased cerebral perfusion
Monitor accurately I&OTo obtain data about renal perfusion and function and the extent of blood loss.
Monitor FHT continuouslyTo provide information regarding fetal distress and/or worsening of condition
Assess uterine irritability, abdominal pain and rigidity.To determine the severity of the placental abruptio and bleeding
Assess skin color, temperature, moisture, turgor, capillary refillTo determine peripheral tissue perfusion like hypervolemia.
Elevate extremity above the level of the heartHelps promote circulation.
Teach patient not to apply uterine pressureUterine pressure can cause pooling of venous blood in lower extremities
Instruct patient and/or SO to report immediately signs and symptoms of thrombosis: (1) pain in leg, groin (2) unilateral leg swelling (3) pale skinTo immediately provide additional interventions