►
CHAPTER 6
ate oral fluid 1I1
• take. Even though
• Teach. to maintain adequ
. .
there 1s an excess of flwd m tissues' the m
• travascular system
.
.
is expenencmg a deficit.
.
• Teach to . include adequate protein in her diet. p rotem
lost
.
in the unne must be replaced to support ti' ssue repair
and
.
.mtam
energy.
ma
( Nursing Diagnosis:ANXIETY,
Related Factors: threat to �atemal and/or fetal well-being and
s 1a and risk s to self and fetu
s. See the
concern about preeclarnp
"
.
1,,
CP
s
,
and "Fear,1" beginning on pp. 10 and
'.Anxiety
ND
c
eri
gen
15, respectively, in Chapter 2.
I Goals, Outcomes, and Evaluation Criteria
• Worn� reports use of relaxation techniques and other coping
strategies.
an verbalizes her fears and concerns freely.
Wom
•
reports decreased feelings and symptoms of anxiety.
Woman
•
I Nursing Activities and Rationales
Assessments
• Assess prior experiences with hypertension and/or pre­
eclampsia. Determines if the woman has prior negative or
positive experiences with hyp ertension that are currently
influencing her reactions to her condition.
• Assess knowledge of hypertension and preeclampsia. The
woman may have received home care before admission,
heard reports from others, looked it up on the Internet, or
received education through the healthcare provider's office.
The nurse needs a baseline to individualize the teaching plan
and eliminate misconceptions to reduce fear and anxiety.
• Assess for factors that create anxiety for the woman.
Determines factors that need to be avoided or altered to pre­
vent increased anxiety during this stressful period of time.
• Assess the woman's support s ystems. Determines if the
woman has adequate support systems or needs to be
referred for community assistance.
Independent Nursing Actions
• Actively listen to the woman's concerns about herself, her
condition, and her fears. Validates the woman's feelings and
conveys a sense of caring and concern. By identifying the
woman's fears and concerns, appropriate interventions can
be planned to reduce or eliminate those fears.
Patient/Family Teaching
• P rovide a safe, calm, quiet environment to teach family and
to provide emotional support. Facilitates coping.
• Encourage verbalization of anxiety, concerns, and fears.
Decreases emotional response and allows venting of feelings.
I Gestational Complications
• Involve woman and family in the management of her pre­
eclamptic condition. Promotes greater sense of control of
the situation.
• Aid woman in identifying and utilizing appropriate coping
strategies and support systems. Reduces fear, anxiety, and
lack of control in unknown situation.
• Teach and explore ways to relax, desensitize anxious feel­
ings, and stop thoughts that are persistent by using relax­
ation, breathing, and other coping strategies. Helps prevent
anxiety, gives the woman something to concentrate on, and
diverts her attention away from fear, which may improve tis­
sue perfusion.
• Teach about plan of care, treatments, and timeline of events.
Facilitates woman's understanding of the possibilities for
treatment in realistic terms, and answers her questions so
she can better verbalize the aspect of care about which she
is anxious.
I Nursing Diagnosis:DEFICIENT
KNOWLEDGE REGARDING
TREATMENT PLAN FOR
HYPERTENSIVE DISORDERS OF
PREGNANCY:MANAGEMENT
OF ACTIVITY, DIET, AND
MEDICATIONS1
Teaching specific to hypertension has been integrated into the
preceding care plans. Al so see the generic NDCP, "Deficient
Knowledge, 1" which begins on p. 13 in Chapter 2.
LATE ANTEPARTUM BLEEDING
Vaginal bleeding may occur any time during pregnancy.
Approximately 50% of bleeding in late pregnancy is due to abrup­
tio placentae and placenta previa. Other causes are vaso previa,
invasive placenta, cervical carcinoma, polyps, cervical or vaginal
infection, velamentous insertion of the cord, and placenta suc­
centuriate. This care plan will focus on the two most common.
An abruptio placenta is the detachment of all or part of a nor­
mal placenta from its implantation site in the uterus. It occur s in
approximately 1% of pregnancies with increased incidence in
sub sequent pregnancies. Abruption is cla ss ified as grade 1 (mild,
10-20% separation), grade 2 (moderate, 20-50% separation), or
grade 3 (severe, greater than 50% separation). Maternal bleeding
is cla ssified as marginal or apparent (separation near the edge with
active bleeding), central or concealed (separation at center with
entrapment of blood), and missed or combined ( with separation at
edge and center of placenta, with some active bleeding and some
179
180
SECTION 111
I Antepartum Care
.
labor in
trapped). Abruptio placentae can occu r pnor to or during
. ng
bleedi
l
vagina
of
cause
g
leadin
a
is
about 196 of pregnancies and
in the last half of gestation.
w r
Placenta previa is the implantation of the placenta in the l� �
h e i�cl­
T
os.
cervical
internal
the
over
r
o
near
uterine segment
dence is 1 in 200 births. Placenta previa is classified according
_
to the degree to which the cervical os is covered by the placenta;
that is, complete (total), incomplete (partial), marginal, or low lying
(planted in the lower uterine segment, but not reaching the os).
Either condition can precipitate a hemorrhagic disorde r with
extensive bleeding and both are medical emergencies.
I
Key Nursing Activities
• Obtain history and assessment to help detennine the cause of
the bleeding.
• Monitor for hemorrhage and shock; institute measures for pre­
vention or early treatment.
• Monitor for fetal well-being and assess for presence of fetal dis­
tress and bleeding.
• Monitor fo r and assist with preventing the onset of labor.
• Provide emotional support and information.
I
Etiologies and Risk Factors
The etiologies of abruptio placentae and placenta previa are
unknown. Risk factors fo r abruptio placentae include pregnancy­
induced or chronic hypertension, previous abruption in a previ­
ous pregnancy, trauma to the abdomen, cigarette use, cocaine
use, PROM, hydramnios, infection, advanced maternal age, clot­
ting disorders, and hyp erhomocystinu ria. Complications include
shock, disseminated int ravascular coagulation, renal failure, and
pituitary necrosis (Sheehan syndrome) with resulting disruption
of lactation. Bleeding in the early part of pregnancy is associated
with increased risk for abruption. Perinatal morality is app roxi­
mately 14 in 1,000. Other p roblems are fetal hypoxia, prematurity,
intrauterine growth restriction, and neurologic defects.
Factors that increase the risk of placenta previa are previous pla­
centa p revia, endometrial scarring from previous uterine su rgeries (including cesarean section and induced abortion), decreased
endomet rial vascularization (hypertension, diabetes, uterine
tumor, drug usage, cigarette smoking, advancing maternal age),
and increased placental mass as in multiple pregnancy. Maternal
complications include hemorrhage and hypovolemic shock, invasive placenta (acc rete, inc reta, and perc reta), septicemia , thrombosis, renal failure, Rh sensitization, and postpartum anemia .
Fetal and neonatal effects include prematurity, malpresentation,
intrauterine growth restriction, and fetal anemia (Gilbert, 2010).
I
Signs and Symptoms
Suspect placenta previa or placental abruption whenever there is
vaginal bleeding after 20 weeks' gestation.
Abruptio Placentae
vaginal bleeding a�d abdomin
Classic p resentation is
al
_
can occur w1� neither of the s Pain�,
tion
abrup
ever,
w
e. lh
ho
correlates _ with �e risk of Still
extent of the abruption
birth_
present as d1sse�ated intr av
T his condition can
ascuJar
e ed ab1:11phon. Sympto
ms vary
coagulopathy in severe con� �
tion, which can be mild, mo
cond
the
1
of
ee
r
deg
the
with
der.
t.
ate, or severe, as explained nex
• Mild. Vital signs normal, total blood loss less than 500ml,dark
vaginal bleeding (mild to moderate), vague lower abd ominal
or back discomfort, no uterine tenderness or irritability, nor­
mal FHR pattern, normal fibrinogen of 450 mg/dl.
• Moderate. VSs include normal BP, mild shock with mater­
nal tachycardia, narrowed pulse pressure, orthosta tic hyp o.
tension, tachypnea; total blood loss of 1,000-1,500 ml, dark
vaginal bleeding (mild to severe), gradual or abrupt onset of
abdominal pain, uterine tenderness, increased uterine tone,
early signs of disseminated intravascular coagulation (DIC)
and fibrinogen 150-300 mg/dl; FHR shows nonreassuring
signs of possible fetal distress.
• Severe. Moderate shock with decreased maternal BP, mater­
nal tachycardia, narrowed pulse pressure, severe orthostatic
hypotension, significant tachypnea; total blood loss more
than 1,500 ml; dark vaginal bleeding, moderate to exces­
sive; abrupt onset of uterine pain ( tearing, knifelike, con­
tinuous); developing DIC; fibrinogen less than 150 mg/di;
FHR shows signs of fetal distress; and fetal death can occur.
DIC is a secondary event activated by a lack of coagulation
factors. The process of fibrinolysis activation in response to
coagulation occurs, creating a cascade that results in ram·
pant coagulation and simultaneous massive bleeding, both
internal and external with resultant ischemia. Refer to a
maternity care textbook, critical care textbook, or the collab­
orative care plan, "Disseminated Intravascular Coagulation;
beginning on p. 26 in Chapter 3.
Placenta Previa
Two classical p resentations of placenta previa are antepartu m
_
hemorrhage (painless, bright red) andfetal ma/presentation ID
!ater pregnancy (fetus stays high because placenta is occupy·
i�g lower uterine segment). Early diagnosis of placenta P
�
via can change with progression of pregnancy, and nonn
_
migration of the placenta can result in normal placement ID
90% of cases detected within the first half of the pregnancy,
I
Diagnostic Studies
• Transabdominal and
transvaginal ultrasound. Rules out or con·
firms placenta previa because
o
it identifies placental locati �
determines degree of separa .
poSI·
g
tion and presence of bleedin ,
.
tion of fetus' fieta! status,
and gestational age.
CHAPTER 6
, A,nIUo centesis. Performed with placenta previa to determine
fetal lu ng maturity with lecithin/sphingomyelin ratio or pres­
ence 0ffetal glycerol.
Speculum exam. Rules out local causes of bleeding (cervicitis,
cer vical polyps, heavy show, cervical carcinoma); performed if
ultras ound reveals a normally implanted placenta; preferably
done only after 34 weeks' gestation.
, CBC, platel ets, librino gen, coagulation studies. Decreased Hgb
and Hct, possible elevated WBC. Low platelets and decreased
fibrinogen indicate progressing disseminated intravascular
coag ulopathy (DIC). Coagulation studies important for DIC
treatment.
, K]eihauer-Betke test on maternal blood; or amniotic fluid index
on amniotic fluid. Detects fetal blo od in amniotic fluid and
estimates fetal blood loss. Allows quantification of fetomater­
nal transfusion to guide dosing of Rh(0) immunoglobulin for
Rh-negative women.
I Medical Management
Medical management varies with the gestational age of the fetus,
fetal well-being or compromise, an d the severity of blood loss
occurring from the placenta previa or abruptio placenta.
Abruptio Placentae
Delivery is the treatment of choice if the fetus is at term or
if the fetus or mother is in jeopardy. If fetus is younger than
36 we eks' gestation and not in distress, and if bleeding is not
severe, expectant management may be used.
Abruption Mild and Bleeding Minimal, Gestation
Preterm
• Obse rvation in hospital to facilitate rapid intervention with
cesarean delivery.
• Close observation for signs of concealed or external
bleeding.
• Fetal surve illance and monitoring until 72 hours have
passed without bleeding, hypertension, or abnormal FHR
pattern.
• Monitor for preterm labor; tocolysis is contraindicated.
Corticosteroid s given if in dicated. Accelerates fetal lung
maturity.
Moderate to Severe Bleeding, Any Gestation
• Monitor maternal volume status; pad count an d weighing
for blood loss calculation.
• IV hydration and volume expansion; accurate intake an d
output documentation.
• Bloo d administration, cryoprecipitate, platelets, fresh frozen
plasma replacements.
• Oxygen therapy.
• Correct coagulation defect ifpresent.
I Gestational Complications
, Vaginal or cesarean delivery; use of oxytocin to induce labor
contraindicated.
Placenta Previa
Expectant Management
, Observation and probable hospitalization (if fetus is young­
er than 36 weeks and bleeding is minimal or has stopp ed).
• Bed rest with bathroom privileges (if fetus is y ounger than
36 weeks and bleeding is minimal or has stopped)•
• Close observation for bleeding. Ho ld maternal bloo d sam­
ple at all times for immediate type and cross-match.
, IV infusions; then heparin lock to maintain venous access.
Continuous fetal monito ring initially, then every 4 hours
once stabilized. If bleeding continues, fetus is older than 36
weeks, fetal lung maturity has been documented by amnio­
centesis, or labor begins, cesarean birth is performed. If pre­
via is partial or low lying and bleeding is minimal, vaginal
delivery may be attempted.
, Ultrasonography frequently until term; amniotic fluid
index checked with NST, and modified biophysical p ro­
file performed twice we ekly. Contraction stress tests
contraindicated.
• Corticosteroids. Accelerate fetal lung maturation between
24 and 34 wee ks' gestation.
• Monitor for signs of preterm uterine contraction; adminis­
tration of tocolytics, preferablymagnesium sulfate. Prevents
prete rm labor.
• Initiate iron supplementation. Builds iron stores.
• Amniocentesis. Determines lung maturity between 34 and 36
weeks because risk for bleeding increases with gestational age.
I Collaborative Problems
Potential complications of placenta previa or placental abruption
include the following:
• Hemorrhag e, hypovolemic shock
postpartum)
• DIC
• P reterm birth (greate st risk to fetus)
• PROM
• Fetal hyp oxia
• Anemia (antepartal or postpartal)
• Infection (antepartal or postpartal)
(antepartum
and/or
COLLABORATIVE (STANDARDIZED)
CARE FOR ALL WOMEN WITH
ANTEPARTAL HEMORRHAGES
Perform comprehensive asse ssment to id entify ind ivid ual n e eds
for te aching, emo tional support, and physical care.
181
1
182 SECTION 111 I Antepartum
Care
I Potential Complications of
Abruptio Placenta or Placenta
Previa: HEMORRHAGE,
HYPOVOLEMIC SHOCK, DIC
• coIIaborattve
Refer to the gen enc
•
care plans, "Potential
.
�omplicatto. n: Disseminated lntravascular Coagulation" and
Potential Complication: Hemorrhage," beginning on pp. 26 and
28, respectively, in Chapter 3.
Focus Assessments
• Assess vital signs and assess for vaginal bleeding, abdominal
tenderness, pain, and rigidity. Helps differentiate abruptio
place�ta from placenta previa. Detects blood loss and pro­
gressing condition to alert provider of need to escalate care.
• Assess level of consciousness. Hypovolemia decreases the
amount of circulating blood and therefore oxygen delivered to
the maternal brain, causing decreased level of consciousness.
• Assess pulse oximetry. Evaluates level of oxygenation and
effectiveness of treatments.
• Measure I and 0, andinsertindwellingurinarycathetet:Urine out­
put is a betterindicatorofbloodloss thanvitalsigns. Vital signs may
be normal even with heavy blood loss because of the increased
volume of blood during pregnancy. I and O indicatesadequacyof
renalperlusionandprovidesmeasureoffluid lossandadequacyof
fluid replac.ement Output of30 ml/hr reflects adequate renal per­
fusion; this varies, though, depending on rate offluid replacement
As a rule, I and O should be approximately equal. Maintain Nline
or N access as detenninedbymatemalstability.
• Assess hemodynamic monitoring (e.g., central venous pressure)
if ordered. For early detennination of severity of blood loss.
• Review fibrin split products and coagulation studies,
including fibrinogen levels, platelet count, activated partial
thromboplastin, and partial thromboplastin time and pro­
thrombin time. Provides information about the cause of the
bleeding. Presence of fibrin split products, decreased platelet
and Jibrinogen levels, and prolonged partial thromboplastin
time and prothrombin time are signs of DIC. Fibrinogen
level should be at least I 00 mg/ di for adequate clotting to
occur. Clotting studies may be repeated frequently.
Assess clot retraction. If blood clots in a plain glass (red­
top) tube within IO minutes, it contains at least 100 mg/di
fibrinogen. 1his is a good way to check blood-clotting ability
while waiting for results of formal clotting studies.
• Monitor for hemolytic or allergic reaction to blood prod­
ucts, if administered. Allows for early intervention, which
may prevent serious complication.
• Institute continuous fetal monitoring. Assesses fetal status
and distress and assesses for uterine irritability. Follow plans
for fetal surveillance.
• Assess for persistent and increased bleeding. Indi ca
e
need to prepare the woman for cesarean bir th. Do t s tbe
Preoi>era.
tive teaching and answer all questions.
Preventive Nursing Activities
• Institute bed rest, usually with bathroom privileges.Artl..<...._
stimulates bleeding and increases oxygen demands. ---•u.7
• Avoid vaginal and rectal exams. May increase am
OUnt of
bleeding, especially in placenta previa.
• Administer corticosteroids as prescribed. Enhance s £eta!
lung maturity.
• Administer iron as prescribed. Builds iron stores.
• Administer blood as prescribed. Fresh frozen plasma
cryoprecipitate may be given to maintain a fibrinogen
of at least 100-150 mg/di. In addition to decreasing BP
and uteroplacental and maternal tissue perfusion, maternal
hemorrhage results in a loss of formed elements ofthe blood
(e.g., erythrocytes). Whole blood replaces formed ele­
ments, increases the oxygen-carrying capacity of the blood,
and helps to prevent fetal hyp oxia and/or fetal death.
• Obtain Rh antibody titer as ordered. Rarely, Rh sensitiza­
tion occurs when fetal blood enters the maternal circulation.
An Rh-negative woman may be given RhoD immune globu­
lin if the fetus is Rh-positive.
• Prepare for immediate cesarean birth. If vaginal delivery is
not possible (e.g., in most cases of placenta previa), and if
bleeding is excessive, fetal distress occurs, or if labor can­
not be stopped, surgery may be needed to save the life ofthe
baby and/or the mother. Profound hemorrhage can occur al
anytime and without warning.
• For women being managed expectantly at home, teach the
importance of bed rest, as well as symptoms of complica­
tions (e.g., bleeding, UCs) that must be reported. Helps to
ensure that the woman will comply with the therapeutic regi·
men and will contact the care provider for timely interven·
tion. Include daily fetal activity charts, pelvic rest, and need
for weekly biophysical profile and doctor's visits in teaching.
• Provide continuous emotional support. Prolonged hospi­
talization with bed rest is difficult. The mother's concern for
the outcome of the pregnancy is continually present.
ie:
I Potential Complication of
-
Abruptio Placentae or Placenta
Previa: PRETERM BIRTH, PROM
Focus Assessments
ot
• Assess uterine contractions. Indicates on set of !ab
re
efo
b
.,
. (e.g
May require administration of tocolytics
one
te
V
e).
ur
36 weeks' gestation, if fetal lungs are mat
CHAPT ER 6
•
•
•
•
hyperstimulation may be noted in cases of abruptio
placentae.
IfUCs occur, notify care provider, do not do vaginal exam.
Exam may need to be done with speculum to avoid digital
stimulation if low-lying placenta. If cervical dilation occurs
along with UCs, it will probably not be possible to maintain
the pregnancy.
Assess for rupture of membranes. Indicates the likelihood
that the pregnancy cannot be maintained; increases the risk
for infection.
Assist with amniocentesis. In placenta previa, determines
lecithin/sphingomyelin ratio for fetal lung maturity. ·
Fetal surveillance (e.g., monitoring, fetal activity, NST, BPP,
amniocentesis). Determines fetal well-being, and information used in decisions about continuing the pregnancy.
Preventive Nursing Activities
• Advise against intercourse, nipple stimulation, and any
activity that produces orgasm. Orgasm involves rhythmic
contractions of the uterus. Nipple stimulation and prostaglandins in semen can stimulate UCs even if orgasm does
not occur.
• Prepare for complications of hemorrhage and birth. Infant
may need to be resuscitated. Further bleeding may occur.
I Potential Complication of
Abruptio Placentae or Placenta
Previa: FETAL HYPOXIA
Focus Assessments
• Monitor FHR continuously. Assesses fetal well-being. Fetus
responds to hypoxia first with tachycardia and later with
bradycardia. Late decelerations and loss of FHR variability
are also nonreassuring.
• Assess fetal movement. Fetus responds to hypoxia first with
increased activity and later with decreased activity.
• Assess fetal BPP. Noninvasive way to evaluate fetal status
and determine the need for birth. Fetal response to hypoxia
is alteration in movement, muscle tone, breathing, and heart
rate pattern. BPP is an accurate indicator of impending fetal
death.
·
• Assess lecithin/sphingomyelin ratio. Determines fetal
lung maturity and helps in decision making about medical interventions. May not be needed if corticosteroids are
administered.
• Perform NST. Evaluates changes in FHR in response to fetal
movements. A reactive test suggests an intact fetal central
nervous system; a nonreactive test suggests fetal hypoxia
and the need for further tests.
I Gestational Complications
183
• Review Kleihauer-Betke test on maternal blood, or amniotic fluid index test on amniotic flu.id. Detects fetal blood in
amniotic fluid and estimates fetal blood loss.
• Assess maternal blood loss. Maternal blood loss reduces
uteroplacental perfusion.
Preventive Nursing Activities
• Administer blood as ordered. In addition to decreasing BP
and uteroplacental perfusion, maternal hemorrhage results
in a loss of formed elements of the blood (e.g., erythrocytes). Whole blood replaces formed elements, increases
the oxygen-carrying capacity of the blood, and helps to prevent fetal hypoxia and/ or fetal death.
• Have the woman assume lateral position (alternating left
and right) unless contraindicated. If supine position must
be used, elevate hips. Promotes venous return by relieving
pressure on the aorta and inferior vena cava. 1his increases
uteroplacental circulation and fetal oxygenation. Elevating
the hips in supine position prevents compression of the
vena cava. Both positions help ensure adequate blood supply to the maternal brain.
• Avoid Trendelenburg position. May compromise maternal
respirations and, therefore, oxygenation.
• Administer oxygen per order or protocol. Increases the oxygen available to the fetus. Because total maternal RBCs are
reduced with bleeding, it is important that the remaining
hemoglobin be fully saturated with oxygen.
• Stop oxytocin irnrnediately if it is being used. Oxytocin
stimulates UCs, which may be necessary to delay delivery,
prevent vaginal birth until cesarean delivery is accomplished, or relieve stress on the fetus.
• Administer betamethasone per order or protocol.
Accelerates fetal lung maturation when it is anticipated that
gestation will not continue to term.
• Prepare for maternal and neonatal complications with birth;
e.g., insert a large-bore (16-gauge) needle for IV line. A
large-bore needle allows for rapid infusion ofblood.
• Abruptio Placentae. Vaginal birth is often feasible and
is desirable when there is severe coagulopathy or fetal
demise. Perinatal mortality is high because of fetal
hypoxia, preterm birth, and small-for-gestationalage status that accompany antepartal hemorrhagic
conditions.
• Placenta Previa. Cesarean birth is usually necessary.
Bleeding may continue even after birth of the infant
because the living ligature (interlacing muscles) is
absent in the lower part of the uterus where the placenta
was implanted.
• For a woman being managed at home, teach to monitor
fetal activity, fetal movement counting, and signs of labor.
Establishes fetal viability and ensures that the woman will
know when to contact healthcare provider or birthing center.
I]
184
SECTION 111 I Antepartum Care
I Potential Complication of
Abruptio Placentae or Placenta
Previa: ANEMIA
Refe r to the generic collaborative care plan "Potential
Complication: Anemia," which begins on p. 25 in Chapter 3.
Focus Assessments
• Assess Hgb and HcL The Hct reflects the RBC volume
which is decreased in acute and chronic blood loss.
• Temperature and other signs of infection. Anemia increas­
es the woman's risk for infection. Loss of RBCs alfects the
immune system's ability to fight infection.
Preventive Nursing Activities
• Administer iron supplement as prescribed. Builds iron
stores.
• Be prepared for complications at birth. Anemia decreases
the woman's ability to tolerate blood loss at birth.
I Potential Complication
of Abruptio Placentae or
Placenta Previa: INTRAUTERINE
INFECTION
Refer to the generic collaborative care plan, "Potential
Complication: Infection," which be gins on p. 29 in Chapter 3.
Focus Assessments
• Assess VSs and for indicators of infections. Chills, fever,and
increased pulse, respirations, and BP are indicators of infec­
tion that can result from exposure of placental tissue and
lowered resistance secondary to an emia.
• Monitor WBC count and differential. WBC count greater
than 15,000 per mm' and a differential shift to the left are
associated with infection. In pregnancy, a normal WBC
count may be slightly higher than the nonpregnant normal
of5,000to!0,000mm3•
• Monitor laboratory results for RBC count and erythrocyte
sedime ntation rate. Increased RBCs and erythrocyte sedi­
mentation rate are signs of infection.
• Assess for uterine tenderness and malodorous vaginal dis­
charge. These are early signs of reproductive tract infection.
INDIVIDUALIZED (NURSING
DIAGNOSIS) CARE PLANS
The care plans in this section were d esigned to address unique
patient needs.
I Nursing Diagnosis: ANXIETv/­
FEAR 1
R,/at,d Factors: seriousness of maternal condition and th,
1
fetal harm or fetal demise. Refer to the generic NDCPs "An,;" �
and "F ear,'" which begin on p. 1 0 and 15, respective!y,'in Cha�
2.
I
Goals, Outcomes, and Evaluation Criteria
I
Nursing Activities and Rationales
Woman and/or partner (family):
• Verbalize and demonstrate ability to concentrate.
• Report adequate sleep and rest.
• Report that anxious feelings are tolerable/manageable.
• Ask for help, as needed.
Independent Nursing Actions
• Acknowledge and facilitate the woman's spiritual and cul­
tural needs. Spiritual support helps relieve anxiety. In th,
event of fetal death, the mother may have specific wishos
regarding baptism of the infant and disposal/burial of the
products of conception.
• Use a calm, reassuring, supportive approach. Facilitates cop­
ing. Women take cues from their caregivers' b ehavior; a bur·
ried,tense nurse provokes more anxiety.
• Involve the woman and her family in decision making 11
much as possible, but do not insist on participation during
periods of high anxiety. W hen anxiety level is high, it inlff•
feres with cognitive functioning; efforts to make decisions
at such a time create more anxiety.
• Maintain a presence at the bedside during periods of"".'.
ety/fear; use silence, as appropriate. Do not necessarilY
expect verbal interaction from the woman. Promotes safety
and reduces fear; if the woman is overwhelmed with stin>uli,
:i
talking may add even more stress.
Encourage an attitude of realistic hope. Although the 51
lion may be grave, overall maternal morbidity is only a,;:.
5 96 and mortality is less than 1 96 with placenta P= ·
1'
greatest risk to the fetus is preterm birth. With abruptl? pta!
centae, the maternal mortality rate is about 196; perin"
mortality ranges from 1596 to 3 096.
he em<>• Encourage talking or crying as a means to decrease t
tional response. Releases tension.
o,,,..,·,
Communicate empathy and understanding of th• � hJlld,
experience, either verbally or with touch (e.g., h o ure at
apply light touch on the shoulder or geo �7: g of
liO
wrist). Helps to reduce anxiety by promoung
unical'
n
onu
c
d
safety and trust. Touch can be reassuring an
10
caring.
. ei plail>
,
• Involve significant others in the woman s ca rt:• he 111oSI
e
r
eiv
them how they can help. The woman may rec
d•