- Abruptio placentae involves the premature separation of the placenta from the uterine wall before delivery, leading to a disruption in the normal exchange of oxygen and nutrients between the mother and fetus.
- The separation can create a hematoma between the placenta and the uterine wall, causing bleeding into the maternal compartment and reducing the blood supply to the fetus.
- The compromised blood flow to the uterus results in uterine ischemia, leading to intense uterine contractions, abdominal pain, and uterine tenderness.
- The bleeding may be concealed within the uterine cavity or manifest externally, contributing to the risk of maternal hemorrhage and hypovolemic shock.
- Decreased oxygen and nutrient supply to the fetus due to the placental separation can result in fetal distress, evidenced by non-reassuring fetal heart rate patterns and potential adverse perinatal outcomes.
Etiology of Abruptio Placentae/Placental Abruption:
- Hypertension:
- Chronic hypertension or pregnancy-induced hypertension (preeclampsia) increases the risk of abruptio placentae due to vascular changes affecting the placental circulation.
- Trauma to the abdomen, such as from motor vehicle accidents or domestic violence, can lead to abruptio placentae, especially in the presence of a predisposing factor like hypertension.
- Women of advanced maternal age have a higher risk of placental abruption, possibly due to age-related changes in blood vessels and increased incidence of hypertension.
- Substance abuse, including tobacco smoking, cocaine use, and certain medications, can contribute to abruptio placentae by affecting blood flow and increasing the risk of hypertension.
- Conditions that cause rapid uterine expansion, such as multiple gestations (twins or more) or polyhydramnios (excessive amniotic fluid), may predispose the uterus to abruptio placentae.
Desired Outcome of Nursing Care for Abruptio Placentae/Placental Abruption:
- Stabilization of Maternal Vital Signs:
- Ensure the mother’s vital signs, including blood pressure, heart rate, and respiratory rate, are within normal ranges to prevent maternal compromise.
- Control and minimize hemorrhage to prevent hypovolemic shock and maintain adequate perfusion to vital organs.
- Monitor fetal heart rate patterns to assess fetal well-being and intervene promptly if signs of fetal distress are present.
- Prevent complications such as disseminated intravascular coagulation (DIC) and organ failure by closely monitoring laboratory values and providing appropriate interventions.
- Offer emotional support and education to the mother and her family regarding the condition, potential outcomes, and the importance of compliance with medical recommendations.
Abruptio Placentae / Placental abruption Nursing Care Plan
Subjective Data:
- Abdominal pain
- Uterine tenderness
- Back pain
- Constant uterine contractions
Objective Data:
- Vaginal bleeding
- Back-to-back uterine contractions
- Firmness of uterus on palpation
- Advanced abruption and severe blood loss may lead to shock
- Tachycardia
- Hypotension
Nursing Assessment for Abruptio Placentae/Placental Abruption:
- Maternal Vital Signs:
- Monitor blood pressure, heart rate, respiratory rate, and temperature regularly to detect signs of hypovolemic shock or maternal compromise.
- Assess the frequency, duration, and intensity of uterine contractions to identify abnormalities that may contribute to placental separation.
- Perform regular abdominal examinations to assess for uterine tenderness, rigidity, or distension, which may indicate abruptio placentae.
- Monitor the amount, color, and consistency of vaginal bleeding to gauge the severity of hemorrhage and guide interventions.
- Continuously monitor the fetal heart rate to detect any signs of fetal distress or non-reassuring patterns.
- Evaluate the mother’s pain level and characteristics, as abruptio placentae is often associated with abdominal pain or back pain.
- Monitor laboratory values, including coagulation studies (PT, APTT), complete blood count (CBC), and fibrinogen levels, to assess for complications such as DIC.
- Assess the emotional well-being of the mother and her support system, providing emotional support and addressing concerns.
Implementation for Abruptio Placentae/Placental Abruption:
- Emergency Interventions:
- Initiate emergency measures, including administering oxygen therapy, establishing intravenous access, and preparing for blood transfusions, to stabilize the mother and address immediate concerns.
- Maintain continuous fetal heart rate monitoring to promptly identify any signs of fetal distress and facilitate timely interventions.
- Administer intravenous fluids judiciously to address hypovolemia and maintain adequate perfusion to vital organs, helping prevent maternal shock.
- Administer blood products, such as packed red blood cells and clotting factors, as indicated by laboratory values, to manage and correct coagulation abnormalities.
- Collaborate with the healthcare team for potential surgical interventions, such as an emergency cesarean section, if the condition warrants prompt delivery for maternal or fetal well-being.
Nursing Interventions and Rationales
Nursing Intervention (ADPIE) Rationale Assess and monitor vaginal bleeding Excessive bleeding may result in shock. Amount of obvious blood may not fully indicate severity due to possible internal bleeding Obtain history from patient Determine time bleeding began, any history of pregnancy complications or abdominal/uterine trauma Place patient on bed rest in lateral position This position helps avoid pressure on the vena cava to avoid decreased cardiac output Initiate IV access with large bore line IV fluids will be given to manage hypovolemia and blood transfusion may be required Assess abdomen for uterine tenderness and contractions Uterus may be tender upon palpation, tense and rigid. Cool compresses to the forehead
Deep breathing techniques
Abdominal, back and uterine pain may accompany bleeding and at times may be severe, especially with contractions.
Analgesics as appropriate
In addition to IV fluids, corticosteroids may be given to speed up fetal lung development if delivery is necessary.
Evaluation for Abruptio Placentae/Placental Abruption:
- Maternal Stability:
- Assess the stabilization of maternal vital signs and overall condition, ensuring that blood pressure, heart rate, and respiratory rate are within normal ranges.
- Evaluate the effectiveness of interventions in controlling hemorrhage, monitoring ongoing blood loss and adjusting treatment as needed.
- Review fetal monitoring records to assess the baby’s well-being and response to interventions, ensuring that any signs of distress are promptly addressed.
- Monitor for and evaluate the prevention of complications such as disseminated intravascular coagulation (DIC) by regularly assessing laboratory values.
- Evaluate the emotional well-being of the mother and family, ensuring they have received adequate support, information, and resources to cope with the traumatic event.
References
- https://my.clevelandclinic.org/health/diseases/9435-placental-abruption
- https://medlineplus.gov/ency/patientinstructions/000605.htm
- https://americanpregnancy.org/healthy-pregnancy/pregnancy-complications/placental-abruption/
View the FULL Outline
When you start a FREE trial you gain access to the full outline as well as:
- SIMCLEX (NCLEX Simulator)
- 6,500+ Practice NCLEX Questions
- 2,000+ HD Videos
- 300+ Nursing Cheatsheets
“Would suggest to all nursing students . . . Guaranteed to ease the stress!”
Transcript
Hi everyone, today, we're going to be creating a nursing care plan for abruptio placentae or placental abruption. So, let's get started. First, we're going to be going over the pathophysiology. So abruptio placentae or placental abruption is when the placenta partially or completely detaches prematurely from the uterus. Nursing considerations. We want to assess vaginal bleeding, bedrest, managing pain, administering medications, and fetal monitoring Desired outcomes: the patient will have no, or minimal bleeding, and pain will be controlled. Fetus will show no signs of his distress. And so here we have an image to show. So, you're going to see all this bleeding all right here, because it's separated from the uterus right here. And you can see over here, there's this internal bleeding here and how it's separated there from the uterus.
So now we're going to go over the care plan. We're going to be writing down some subjective data and some objective data. So, what are we going to see with patients? They are going to have some abdominal pain. They're going to have some uterine tenderness, possibly some back pain. Some objective data: they're going to have some vaginal bleeding and some firmness of the uterus. So constant uterine contractions are another thing that these patients may have or an advanced abruption and severe loss. It may lead to tachycardia and hypotension.
So, interventions, we want to make sure we're going to assess and monitor vaginal bleeding, the maternal vital signs. We also want to make sure we're getting a patient history. Excessive bleeding may result in shock. So, the amount of obvious blood may not fully indicate the severity due to possible internal bleeding. We want to watch for signs of hypovolemia to tachycardia, and hypotension. We want to determine time bleeding began and any history of pregnancy complications or abdominal uterine trauma that the mom may have. We also want to make sure we're placing the patient on bedrest in a lateral position. So, we want to do bedrest and we want to make sure it's lateral positioning. This position's going to help avoid pressure on the vena cava to avoid any sort of decreased cardiac output. That is why we want them in the lateral position. We also want to make sure that we initiate any sort of IV access with a large bore line. We're going to want to make sure we're giving IV fluids and able to manage the hypovolemia and possibly give a blood transfusion. We want to make sure we're assessing the abdomen for uterine tenderness and contractions. So, the abdomen we're going to be assessing. The uterus may be tender upon palpation and tense and rigid. So, a massage may help to slow bleeding from the uterine wall. And we're going to place and observe external fetal monitoring for signs of fetal distress. So, we're going to want to make sure that we're doing fetal monitoring. This allows you to monitor the fetal heart rate and contractions to observe for the variability and responsiveness of the fetal heart rate. A lack of variability or deceleration will indicate fetal distress. We want to make sure that we're assessing and managing pain So we can do nonpharmacological: massage, guided imagery, cool compresses. Abdominal, back, and uterine pain can all accompany bleeding. And at times it may be severe, especially with contractions. So, you want to make sure we're providing any sort of alternative options for pain relief, if available. Otherwise, you may end up giving them some by mouth pain medication. So other medications that we may be giving the patient corticosteroids, analgesics for the pain, and oxytocin. So, in addition to IV fluids, corticosteroids may be given to speed up the fetal lung development. If delivery is necessary oxytocin to is given after delivery to decrease hemorrhage.
Alright, we're going to move on to the key points. So, the placenta partially or completely will detach prematurely from the uterus. Risk factors will include abdominal trauma, vascular disorders, hypertension, and advanced maternal age. Some subjective and objective data that you're going to see in these patients: they'll complain of abdominal pain, uterine tenderness, bleeding, back-to-back uterine contractions, and firmness of the uterus. We want to make sure we're assessing for that vaginal bleeding, getting a proper history, abdominal tenderness, fetal monitoring, and managing the pain. We want to make sure we're administering the medications as needed, making sure we're promoting bedrest. And there we have that completed care plan.
You guys did amazing. We love you guys. Go out, be your best self today and as always happy nursing.
View the FULL Transcript
When you start a FREE trial you gain access to the full outline as well as:
- SIMCLEX (NCLEX Simulator)
- 6,500+ Practice NCLEX Questions
- 2,000+ HD Videos
- 300+ Nursing Cheatsheets
