OB Antepartum Care Plan

  1. I am doing a care plan on a patient who came in who had fallen, was 36 weeks gestation, and wanted to make sure that everything was okay with the baby.

    I understand that my care plan is mostly going to be "risk for" because other than some bumps and bruises, she was in okay shape.

    Risk for bleeding r/t possible placental abruption r/t fall
    1. assess fetal heart rate via monitor - to monitor for s/s of fetal distress. Make sure there is good variability.
    2. Assess for any contractions - increasing amt/strength of contractions can be indicative of early labor
    3. Asses for vaginal bleeding - vaginal bleeding can indicate early labor
    4. Assess LOC - altered LOC may indicate low fluid volume and bleeding
    5. Assess for abdominal pain and cramping - placental abruption causes the mother severe abdominal pain
    7. Assess BP q 15 min - Low BP indicates hemorrhage and is a late sign of a maternal bleed
    8. Monitor BP for orthostatic changes - postural hypotension is a common manifestation in fluid loss >10mm Hg drop = circ blood volume is decreased by 20% >20-30mm Hg drop = circ blood volume is decreased by 40%
    9. Monitor and document VS - sinus tachycardia may occur with hypovolemia to maintain an effective cardiac output. Usually the pulse is weak and can be irregular. Hypotension is evident in hypovolemia.

    GOAL: Patient will experience adequate fluid volume AEB normotensive BP and HR < 100BPM.

    That's what I've got so far. I'm thinking.... RISK FOR PAIN... could be one... And I'm kind of reaching if I go with risk for infection because of the small abrasion to her knee... Any other good nursing diagnosis'?

    Any input is appreciated! Thank you!
  2. 3 Comments

  3. by   L&DRNJenn
    Whenever anyone falls we always draw "abruption labs". CBC, Fibrin Split Products, Fibrinogen, ABO-RH and a Kleihauer-Betke Stain. We generally observe mom and baby and repeat the blood work in 6-12 hours depending on how often they order it.
  4. by   HoneyDew70
    What about her psychological well-being? Anxiety? Safety teachings?
  5. by   bjb12
    Thank you both. I appreciate it! :-)