NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: Impaired fetal gas Placenta previa After 8 hours of • Assess vital signs • .Provides • After 8 hours of
exchange related nursing (pulse, baseline data nursing
“Bigla na lang to altered blood
is the interventions, respirations, and on maternal interventions, the
akong dinugo (I’m flow and development of the patient will blood pressure blood loss. patient was able
bleeding)” as decreased placenta in the verbalize every 15 to verbalize
verbalized by the surface area of lower uterine understanding of minutes). understanding of
patient. gas exchange at segment, causative factors • Maintain bed rest • Systemic rest is causative factors
site of placental and appropriate or chair rest when mandatory and and appropriate
partially or
Objective: detachment. interventions. indicated. Provide important interventions.
completely frequent rest throughout all
• Changes in covering the periods and phases of
fetal heart internal cervical uninterrupted disease to
rate or fetal os. The cause night time sleep. reduce fatigue,
activity. is unknown, but and improve
strength.
a possible
• Release of • Monitor amount • Provide
meconium. theory states and type of objective
that the embryo bleeding. evidence of
• V/S taken as will implant in bleeding.
follows: the lower • Position mother • To promote
uterine on her left side. placental
T: 36.9 perfusion.
segment if the
P: 96 • Restrict vaginal • Prevents
R: 22 deciduas in the examination. tearing of
Bp: 100/80 uterine fundus placenta if
is not placenta previa
favorable. is the cause of
Complications bleeding.
• Monitor uterine • Assess whether
are immediate
contractions and labor is present
hemorrhage, fetal heart rate by and fetal status
shock, and external monitor. and external
maternal death; system avoids
fetal mortality; cervical trauma.
and post • Maintain positive • Supports
attitude toward mother and
partum about fetal child bonding.
hemorrhage. outcome.

Collaborative:
• Administer • Provides
oxygen as adequate fetal
indicated. oxygenation
despite of
lowered
maternal
circulating
volume.