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!