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    NCP Draft

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    Angelo Mark
    This nursing care plan outlines the interventions, rationale, and evaluations for a patient experiencing vaginal spotting during their delivery room rotation, including establishing rapport, monitoring vital signs, assessing blood loss and hypovolemia, positioning the patient laterally, scheduling rest periods, avoiding exams, conducting additional tests as needed, explaining procedures, and providing psychological support.

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    NCP Draft

    Uploaded by

    Angelo Mark
    13 views9 pages
    This nursing care plan outlines the interventions, rationale, and evaluations for a patient experiencing vaginal spotting during their delivery room rotation, including establishing rapport, monitoring vital signs, assessing blood loss and hypovolemia, positioning the patient laterally, scheduling rest periods, avoiding exams, conducting additional tests as needed, explaining procedures, and providing psychological support.

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    NCP-DRAFT

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    This nursing care plan outlines the interventions, rationale, and evaluations for a patient experiencing vaginal spotting during their delivery room rotation, including establishing rapport, monitoring vital signs, assessing blood loss and hypovolemia, positioning the patient laterally, scheduling rest periods, avoiding exams, conducting additional tests as needed, explaining procedures, and providing psychological support.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    13 views9 pages

    NCP Draft

    Uploaded by

    Angelo Mark
    This nursing care plan outlines the interventions, rationale, and evaluations for a patient experiencing vaginal spotting during their delivery room rotation, including establishing rapport, monitoring vital signs, assessing blood loss and hypovolemia, positioning the patient laterally, scheduling rest periods, avoiding exams, conducting additional tests as needed, explaining procedures, and providing psychological support.

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    A Nursing Care Plan

    In partial fulfillment of the

    requirements in NCM 207 RLE

    DELIVERY ROOM ROTATION

    Submitted to:

    Clinical Instructor

    Submitted by:

    March 20, 2023


    Date Cues Ne Nursing Diagnosis PT. outcome Interventions Implementa Evaluation
    and eds tion
    Time
    March Subjective: H Risk for bleeding In the span of my 8 hours of 1. Establish 1 After the 8
    9, E care, the patient will be able to: rapport hours of
    “wala na as evidence by
    2023 A R: Good rapport nursing
    @8:3 siya nag L vaginal spotting. - The client will have makes the intervention
    0PM T reduced or absence of patient cooperate the patient
    stop ug vaginal spotting or
    H and creates a was able to:
    dugo sukad P Rationale: bleeding. harmonious
    E - The client will display relationship with
    atong gi IE Spotting a pelvic “Goal met”
    R normal vital signs and the patient. It
    ko atong C exam: The cervix stable fetal heart rates. allows the nurse - The
    E (opening to the to understand client
    last maam”
    P and
    T womb) in a communicate has
    2
    Objective: I pregnant woman well with the reduc
    O patient
    - Vagi N has a very good ed
    nal / blood supply. It vagina
    2. Assess
    H
    spotti E can bleed easily a maternal l
    ng A pelvic exam Your spottin
    vital signs.
    L
    - Face T cervix can bleed R: Assess the g.
    grim H after a because it's - The
    client’s pulse,
    M
    ace A highly sensitive respiration, and client
    Vital Signs: N (due to increased displa
    blood pressure
    - BP – A
    G hormones). There every 15 minutes ys a
    120/ E may be slight and apply a norma
    90 M
    spotting (a few pulse oximeter l vital
    - PR – E
    84 N drops of blood on and automatic 3 sign
    bpm T
    the underwear). blood pressure and
    - CR –
    100 There may be a cuff as stable
    bpm
    small amount of necessary. This fetal
    - RR –
    28 pinkish or provides baseline heart
    breat
    brownish mucus data on maternal tone.
    hs
    per discharge. response to
    minut
    Reference: blood loss.
    e
    - T– Vaginal Bleeding 3. Monitor
    36.4 Pregnant More and record
    °C Than 20 Weeks. maternal
    (2022, January 13).
    - G: 1 blood loss
    Advocare Kressville
    - P: 1 and
    Pediatrics. Retrieved
    - T: 1 uterine
    March 20, 2023,
    - P: contractio
    from
    - A: ns.
    http://www.advocare
    - L: kressvillepediatrics.c R: Excess
    om/Vaginal- maternal blood
    4
    Bleeding-Pregnant- loss
    More-Than-20- compromises
    Weeks placental
    perfusion. If
    uterine
    contractions are
    accompanied by
    cervical
    dilatation, bed
    rest and
    medications may
    not be effective
    in maintaining
    the pregnancy. 5
    4. Assess for
    signs of
    hypovole
    mia.
    R: The client
    should be
    assessed for
    signs and
    symptoms of
    hypovolemia.
    The increased
    blood volume of
    pregnancy allows 6

    more than
    normal blood
    loss before
    hypovolemic
    shock processes
    begin.
    5. Place the
    client in a
    lateral
    position.
    R: The lateral
    position relieves
    pressure on the
    inferior vena
    7
    cava and
    enhances
    placental
    circulation and
    oxygen
    exchange. Urge
    the client to rest
    in a left side-lying
    position to help 8

    prevent vena
    cava
    compression.
    6. Schedule
    the client’s
    periods of
    rest and
    activities.
    R: The client may
    avoid strenuous
    activities for 24 to
    48 hours to
    prevent a
    9
    threatened
    abortion,
    assuming the
    threatened
    miscarriage
    involves a live
    fetus and
    presumed
    placental
    bleeding.
    7. Avoid
    vaginal
    10
    examinati
    ons.
    R: Omitting
    vaginal
    examinations
    prevent tearing of
    the placenta if
    placenta previa is
    the cause of the
    bleeding.
    8. Carry
    out/repeat
    NST, as
    indicated.
    R: Electronically
    evaluating the
    FHR response to
    fetal movements
    is useful in
    determining fetal
    well-being
    (reactive test)
    versus hypoxia
    (nonreactive).
    Additionally, this
    assesses
    whether labor
    and fetal status
    are still present.
    9. Assist with
    ultrasonog
    raphy and
    amniocent
    esis.
    Explain
    procedure
    s.
    R: Ultrasound is
    used to
    determine if the
    fetus is living and
    supplies
    information about
    placental and
    fetal well-being.
    10. Provide
    psychologi
    cal and
    emotional
    support to
    the
    patient.
    R: This helps in
    patient
    assurance and
    calming.

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