I. DISEASE DESCRIPTION
Placenta previa occurs when the placenta lies low and covers all or part of the cervix. In normal pregnancy, the placenta will implant into the top or side of the uterus. With placenta previa, the placenta attaches closer to the bottom of the uterus. The placenta can be implanted so low that there is a risk for bleeding to the mother when the cervix dilates. Placenta previa is diagnosed into different classifications. With complete placenta previa, the placenta covers the entire cervical opening. In marginal placenta previa the placenta is measured through ultrasound and is determine to be 2.5 cm or closer to the internal orifice. Those diagnosed with placenta previa are also at a greater risk for placenta abruption. …show more content…
With the use of ultrasound, most women will become diagnosed before a bleeding episode begins. When bleeding is reported, further testing is completed through a transabdominal ultrasound often followed by a transvaginal ultrasound to confirm or rule out the diagnosis. Lab work completed will include: hemoglobin, hematocrit, platelet count, and coagulation status. A type and screen sample is taken to prepare for an emergency situation, in the event that blood products will be needed. If testing confirms a normal implanted placenta, a speculum exam and a coagulation profile may be completed to locate the cause of bleeding (Perry, …show more content…
B. Ineffective tissue perfusion r/t maternal blood loss AEB capillary refill greater than 3 seconds.
Interventions
The nurse will monitor blood pressure, pulse, capillary refill, intake/output, and respirations.
The nurse will encourage bed rest and frequent repositioning.
The nurse will encourage relaxation techniques, guided imagery, and keep the patient informed about all procedures.
Rationales
Close monitoring will reveal changes and response to activity
Frequent repositioning encourages venous return and prevents blood from pooling
Relaxation techniques, a comfortable environment, and knowledge about procedures may reduce stress levels and decrease the risk of vasoconstriction
Outcomes
Patient will have maintain adequate tissue perfusion AEB
B/P normal for patient’s baseline, capillary refill less than 3 seconds, and output of at least 30 ml/hr., and unlabored respirations between 12-20 per minute Extremities warm with the absence of pallor and cyanosis A relaxed appearance and verbalization of feeling
Placenta previa occurs when the placenta lies low and covers all or part of the cervix. In normal pregnancy, the placenta will implant into the top or side of the uterus. With placenta previa, the placenta attaches closer to the bottom of the uterus. The placenta can be implanted so low that there is a risk for bleeding to the mother when the cervix dilates. Placenta previa is diagnosed into different classifications. With complete placenta previa, the placenta covers the entire cervical opening. In marginal placenta previa the placenta is measured through ultrasound and is determine to be 2.5 cm or closer to the internal orifice. Those diagnosed with placenta previa are also at a greater risk for placenta abruption. …show more content…
With the use of ultrasound, most women will become diagnosed before a bleeding episode begins. When bleeding is reported, further testing is completed through a transabdominal ultrasound often followed by a transvaginal ultrasound to confirm or rule out the diagnosis. Lab work completed will include: hemoglobin, hematocrit, platelet count, and coagulation status. A type and screen sample is taken to prepare for an emergency situation, in the event that blood products will be needed. If testing confirms a normal implanted placenta, a speculum exam and a coagulation profile may be completed to locate the cause of bleeding (Perry, …show more content…
B. Ineffective tissue perfusion r/t maternal blood loss AEB capillary refill greater than 3 seconds.
Interventions
The nurse will monitor blood pressure, pulse, capillary refill, intake/output, and respirations.
The nurse will encourage bed rest and frequent repositioning.
The nurse will encourage relaxation techniques, guided imagery, and keep the patient informed about all procedures.
Rationales
Close monitoring will reveal changes and response to activity
Frequent repositioning encourages venous return and prevents blood from pooling
Relaxation techniques, a comfortable environment, and knowledge about procedures may reduce stress levels and decrease the risk of vasoconstriction
Outcomes
Patient will have maintain adequate tissue perfusion AEB
B/P normal for patient’s baseline, capillary refill less than 3 seconds, and output of at least 30 ml/hr., and unlabored respirations between 12-20 per minute Extremities warm with the absence of pallor and cyanosis A relaxed appearance and verbalization of feeling