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. Visit bjb12 profile page

    About bjb12

    Joined: May '10; Posts: 7
    from US


  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! :-)