University of the East

Ramon Magsaysay Memorial Medical Center, Inc.

College of Nursing

NCM109-WORKSHEET

Submitted by:
Ramones, Reina Mae M.
N2A
 HYPEREMESIS GRAVIDARUM
A. Description:
- An uncontrollable and persistent vomiting during the first week of pregnancy and
may continue throughout pregnancy. It is associated with loss of 5% or more of
pregnancy weight, dehydration, elevated blood and urine ketones, acidosis from
starvation alkalosis from loss of hydrochloric acid in the gastric fluids and
hypokalemia. The cause of this is still unknown but it is common to unmarried
women during first and multifetal pregnancies

B. Focus Assessment (Signs and Symptoms)

- Persistent nausea and vomiting
- Loses weight for more than 10 pounds
- Patient always feel dizzy and lightheaded
- Dehydrated

C. Diagnostic and Laboratory Test

1. Hematology Test
 This determines the hemoglobin and hematocrit as it is elevated as a result of
dehydration, which results in hemoconcentration
2. Electrolyte Test
- This can help determine whether there's an electrolyte imbalance in the body and
reveals low sodium, potassium and chloride
3. Creatinine Blood Test
 This measures the level of creatinine in the blood and elevated creatinine levels
indicate renal dysfunction
D. Risk Factors
- Earlier pregnancy, overweight, multiple pregnancy, first time to give birth, the
presence of trophoblastic disease, which involves the abnormal growth of cells inside
the uterus and cholecystitis or peptic ulcer are possible risk factors on this diseases

E. Pathophysiology

F. Nursing Diagnoses by Priority (5)

1. Imbalanced Nutrition: Less than body requirements, related to nausea and persistent
vomiting as evidenced by weight decrease as compared with prepregnant weight
2. Deficient fluid volume related to excessive vomiting as evidenced by fluid and
electrolyte imbalance
3. Anxiety related to effects of hyperemesis on fetal well-being as evidenced by client
statements concern
4. Altered nutrition, less than body requirements, related to prolonged vomiting
 5. High risk for fluid volume deficit related to vomiting secondary to hyperemesis
gravidarum

G. Nursing Care Plan (3)

Assessment Nursing Diagnosis Scientific Rationale Planning Implementation Evaluation

Subjective: Imbalanced Intake of nutrients Goals: Independent: After the nursing

 Reported food Nutrition: Less than insufficient to meet After 2 days of - Determine interventions, the
intake less than body requirements, metabolic needs nursing interventions, patient’s patient abled to:
required daily related to nausea and the patient will be prepregnant weight - exhibit no further
allowances persistent vomiting as Nausea is the feeling able to: - Monitor current weight loss and it
 Reported altered evidenced by weight of want to vomit and - Exhibit no further weight stabilized
taste sensation decrease as compared Vomiting is the weight loss and it - Monitor intake and - tolerate regular
 Lack of interest in with pre-pregnant results in the stabilized output diet with adequate
food weight production of gastric - Tolerate regular - Provide small and nutrients for
 Satiety contents or intestines diet with adequate frequent bland pregnancy with no
immediately after through the mouth. nutrients for meals as client further nausea and
ingesting food Thus they are a pregnancy with no tolerates vomiting
 Abdominal pain common symptom of further nausea and - Conduct health - State the use of
digestive disorders, vomiting teaching about: administered
Objective: but also may occur in  importance of medicine
 Body weight 20% fluid and electrolyte Objectives: contacting - Verbalize
or more under the imbalance. After 1 hour of health care understanding of
ideal nursing interventions, provider if causative factors
the patient will be intractable when known and
 Weakness of
muscle required Source: able to: nausea and necessary
for swallowing or Doenges, M., - State the use of vomiting recur interventions
mastication
Moorhouse, M. and administered  importance of - Verbalize and
Murr, A. (2010). medicine low-fat, high demonstrated
 Poor muscle tone
Nurse’s Pocket Guide - Verbalize protein diet with selection of foods
 Hyperactive
Diagnoses, understanding of fluids between or meals that will
bowel sounds
Prioritized causative factors meals accomplish a
 Pale mucous
Interventions and when known and termination of
membrane
Rationales necessary Dependent: weight loss.
 Abnormal
interventions - Administration of
laboratory studies
Template, K., (2019). - Verbalize and prescribed
Nursing Diagnosis demonstrate antiemetic
Intervention. selection of foods medications
Retrieved from or meals that will
https://nursing- accomplish a Collaboration:
diagnosis- termination of - Advice patient to
intervention.blogspot. weight loss. consult to a
com/2014/08/imbalan dietitian to develop
ced-nutrition-more- optimal diet plan
than-body.html

Subjective: Deficient fluid Deficient fluid Goals: Independent: After the nursing
 Thirst volume related to volume is a state or After 2 days of - Assess Vital Signs interventions, the
 Weakness excessive vomiting as condition where the nursing interventions, - Maintain accurate patient abled to:
 evidenced by fluid fluid output exceeds the patient will be intake and output - Restore her fluid
Objective: and electrolyte the fluid intake. It able to: of the patient and electrolyte
 Sudden weight imbalance happens when water - Restore her fluid - Monitor laboratory balance
loss and electrolytes are and electrolyte values and report - Maintain fluid
 Elevated lost as they exist in balance deviations from volume at a
hematocrit normal body fluids. - Maintain fluid normal functional level
 Change in mental Common sources of volume at a - Monitor daily with normal
state fluid loss are the functional level weight specific gravity,
 Dry skin and gastrointestinal tract, with normal - Have the patient stable vital signs,
mucous polyuria, and specific gravity, begin to drink oral moist mucous
membranes increased perspiration stable vital signs, fluid slowly and membranes, and
 Decreased skin o moist mucous carefully good skin turgor
tongue turgor Source: membranes, and - Assess and - Verbalize
Nurselabs (2019). good skin turgor document skin understanding of
Deficient Fluid turgor, condition of causative factors
Volume. Retrieved Objectives: mucous and purpose of
from After 1 hour of membranes, vital individual
https://nurseslabs.co nursing interventions, signs and urine therapeutic
m/deficient-fluid- the patient will be specific gravity interventions and
volume/ able to: - Discuss factors medications
- Verbalize related to - Demonstrate
understanding of occurrence and behaviors to
causative factors ways that patient monitor and
and purpose of can prevent from correct deficit as
individual dehydration indicated
therapeutic - Review - Verbalize
interventions and medications, its measures that can
medications interactions and be taken to treat or
- Demonstrate side effects prevent fluid
behaviors to volume loss.
monitor and Dependent:
correct deficit as - Administration of
indicated prescribed
- Verbalize antiemetic
measures that can medications
be taken to treat or
prevent fluid Collaboration:
volume loss. Advice patient to
consult to a dietitian
to develop optimal
diet plan

Subjective: Anxiety related to Vague uneasy feeling Goals: Independent: After 1 hour of
 effects of of discomfort by an After 2 days of - Use therapeutic nursing intervention,
hyperemesis on fetal autonomic response. nursing interventions, communication to the patient able to
Objective: well-being as A feeling of the patient will be listen to patient’s exhibit decreased
 Su evidenced by client apprehension caused able to: concern incidence of anxiety
statements concern by anticipation of - E - Provide
danger. It is an - information
altering signal that Objectives: regarding any
warns of impending After 1 hour of potential risks to
danger and enables nursing interventions, the fetus
the individual to take the patient will be - Identify patient’s
 measures to deal with able to: personal strengths
threat - and previous
coping
Source: mechanisms
Doenges, M., - Identify patient’s
Moorhouse, M. and sources of support
Murr, A. (2010). and mobilize
Nurse’s Pocket Guide support person or
Diagnoses, group of her choice
Prioritized
Interventions and Dependent:
Rationales - Administration of
prescribed anti-
anxiety or sedative
medications

Collaboration:
- Advice patient to
consult to social
service as needed
for ongoing
evaluation and
assistance

Nursing Scientific
Assessment Planning Implementation Evaluation
Diagnosis Rationale

Subjective: Anxiety regnancy Goals: Independent: After 1 hour

related to and child After - Use of nursing
Patient effects of birth nursing therapeutic intervention,
"Di ko alam hyperemesis process and interventions communicati the patient
kung on fetal well- care of the , the patient on to listen to able to
makakapag being as newborn will be able patient’s exhibit
normal evidenced by does not to verbalize concern decreased
delivery ako, client match the the - Provide incidence of
basta sabi ng statements environmen importance information anxiety
doctor concern tal context of care regarding any
pahalang lang norms and during potential
si baby" expectation childbearing risks to the
 s process fetus
"Di ko alam - Identify
kung para Objectives: patient’s
saan yung After personal
ferrous nursing strengths and
sulfate" interventions previous
, the patient coping
"Sayang yung will be able mechanisms
gamot, to: - Identify
ibibigay ko na patient’s
lang ba to sa -State the sources of
asawa ko?" use of support and
administered mobilize
Objective: medicine support
-Inadequate person or
knowledge of -Recall the group of her
current different choice
pregnant positions of
status the child Dependent:
-Inadequate inside the - Administratio
prenatal womb n of
knowledge prescribed
-Inadequate -Express antiemetic
access to willingness medications
-Patient failed to have
to follow proper Collaboration:
doctors orders nutrition by - Advice
regarding to stating at patient to
fluid intake as least 3 foods consult to
manifested by to eat and social service
presence of not to eat as needed for
constipation during ongoing
-Pale skin pregnancy evaluation
-Dry skin and
- assistance

H. Nursing Management/ Intervention

- Teach and advise the patient on how to determine and record intake and output
 - Patient should be weighed daily
- Patient should eat every 2 to 3 hours
- Advise the patient to increase water intake
- Provide emotional support
- Nurse will use critical thinking to examine their own biases so that they can provide
comfort and support

I. Medical/ Surgical Management

 Medical Management
o Administration of 3000 mL of an IV solution such as Ringer’s lactate with added
Vitamin B
o Administration of sedative such as phenobarbital to encourage rest
 Surgical Management
o Cesarean Delivery
 This is a surgical delivery of a fetus by an incision through the mother's
abdomen and uterus.
 This will be done because of the low implantation of the placenta \

Mechanism of Adverse Contraindica Nursing

Indications Side Effects
Action Effects tions Responsibilities
Generic Name: Enters target To reduce  Nausea  Unusual  Hypersensit  Monitor patient’s
Methylprednisolo cells and binds nausea and  Vomiting weight ivity to the vital signs
ne to intracellular vomiting  Heartburn gain drug  Assess for history of
corticosteroid  Headache  Bone/join  Infection infections
Brand Name: receptors,  Dizziness t pain  Patients  Do not give live virus
Sodium succinate initiating many  Trouble  Easy who receive vaccines with
complex sleeping bruising immunosup immunosuppressive
Dosage: reactions that
 Appetite  Bleeding pressive doses of
40 mg are responsible  Mental/m doses corticosteroids.
changes
for its anti-
 Increased swe ood  Advise patient to
Route: inflammatory changes report if adverse
ating
IV or IM and  Puffy face effects are
 Pain/redness/s
immunosuppres
welling at the  Slow experienced
Drug sive effects  Administer the drug
injection site wound
Classification: healing slowly
Corticosteroids  Teach the patient the
 Irregular
Heartbeat mechanism of action,
indication, side and
adverse effects, and
contraindication of
the drug
Generic Name: Barbiturates This is a  Nausea  Taggering  Hypersensit  Monitor patient’s
Phenobarbital inhibit impulse sedative and  Vomiting walk ivity to the vital signs
conduction in used to  Dizziness  Clumsine drug  Monitor patient
Brand Name: the ascending encourage rest  Drowsiness ss  Pregnant responses and blood
Solfoton RAS, depress  Excitation  Double  Breastfeedi levels
the cerebral  Headache vision ng  Advise patient to
Dosage: cortex, alter
 Tiredness  Abnormal report if adverse
30-120 mg cerebellar effects are
 Loss of shallow
function, breathing experienced
appetite
Route: depress motor  Fainting  Teach the patient the
PO output and can  Slow mechanism of action,
produce heartbeat indication, side and
Frequency: excitation,
 Severe adverse effects, and
q4-6 hrs sedation, contraindication of
tiredness/
hypnosis, weakness the drug
Drug anesthesia and  Take the drug exactly
 Pale skin.
Classification: deep coma as prescribed
Sedative

J. Drug Analysis
 ECTOPIC PREGNANCY
A. Description
- It is the implantation of fertilized ovum in a site other than the fallopian tube,
abdominal cavity, or cervix.
- This may be caused by tubal damage from pelvic inflammatory disease, previous
tubal surgery, congenital anomalies of the tube, endometriosis, previous EP, presence
of IUD, and in utero exposure to diethylstilbestrol.
- An ectopic pregnancy can't give birth normally as the fertilized egg can't survive, and
when it is left untreated, the growing tissue may cause life-threatening bleeding.

B. Focus Assessment (Signs and Symptoms)

- Missed menstrual period
- Sharp pain in the abdomen, pelvis, shoulder, or neck
- Severe pain that occurs on one side of the abdomen
- vaginal spotting or bleeding (light to heavy)
- Pressure on the rectum
- Fainting or dizziness

C. Diagnostic and Laboratory Test

1. Blood test
- To determine your levels of hCG and progesterone.
- This will also reveal low hemoglobin and hematocrit levels and rising leukocyte
levels
2. Pelvic examination
 This detects tenderness in the fallopian tube or uterus, less enlargement of the
uterus than expected for a pregnancy, or a mass in the pelvic area.
3. Transvaginal ultrasound
- Inserting an instrument into the patient’s vagina to see if a gestational sac is in
the uterus
1. Human Chorionic Gonadotropin (hCG) Test
 This is to check for the hormone hCG in blood or urine
 An abnormal pregnancy is suspected if hCG is present but at lower levels
 If gestational sac cannot be visualized when hCG is present, a diagnosis of
ectopic pregnancy may be made with great accuracy
2. Laparoscopy
 Examination of the peritoneal cavity by means of a laparoscope

D. Risk Factors
- History of sexually transmitted disease
- History of pelvic inflammatory disease
 - History of ectopic pregnancies
- Failed tubal ligation
- Intrauterine device
- Multiple induced abortions
- Maternal age older than 35 years

E. Pathophysiology

F. Nursing Diagnoses by Priority (5)

1. Acute pain related to abdominal bleeding secondary to tubal rupture
2. Anticipatory grieving related to expected pregnancy loss
3. Health-seeking behaviors: Request for information about treatment of Ectopic
Pregnancy and its Long-Term Implications related to stated unfamiliarity with the
condition
4. Grieving related to early loss of pregnancy secondary to ectopic pregnancy

G. Nursing Care Plan (3)

H. Nursing Management/ Intervention

 Monitor for decreasing hematocrit levels and pain that would indicate a ruptured
ectopic pregnancy
 Administration of analgesics and evaluate their effectiveness so that pain can be
controlled
 Explain the adverse effects of the methotrexate such as nausea and vomiting
 Advise patient to refrain from drinking alcohol that decreases effectiveness, ingesting
vitamins that contains folic acid and having sexual intercourse until hCG is not
detectable
 Provide support to resolve intense emotions that may include anger, grief, guilt and
self blame

I. Medical/ Surgical Management

 Medical
 Methotrexate
- Used for woman who desires future pregnancy if her ectopic pregnancy is
unruptured and of 4 cm size or less and if her condition is stable
- This is to control bleeding and prevent hypovolemic shock
 Surgical
 Salpingostomy via laparoscope
- Surgical incision on an opening into the fallopian tube, but the tube itself is
not removed in this procedure
J. Drug Analysis
1. Methotrexate
 HYDATIDIFORM MOLE (H. MOLE)
A. Description
- It is a disease that has abnormal development that occurs on the placenta, resulting in
hydropic vesicles and trophoblastic tissue proliferates. This disease results of
developing choriocarcinoma which is a form of cancer from the trophoblastic tissue.
- This is classified into two types: A complete mole which develops from an ovum
containing an empty egg which is fertilized by a normal sperm, in which the embryo
dies very early, no circulation established while the tissue of the placenta is abnormal
and swollen that forms fluid-filled cysts. While, a partial mole, there could be an
abnormal tissue of the placenta are formed with a normal placental tissue.

B. Focus Assessment (Signs and Symptoms)

 Increased level of hCG
 Sepsis
 Low blood pressure
 Preeclampsia
 During the first trimester, there are vaginal bleeding that is dark brown to bright red
 Excessive nausea and vomiting
 Vaginal passage of grapelike cysts
 Pain or pressure in the pelvis
 Infection of the uterus
 Sepsis
 Low blood pressure
 Early development of Preeclampsia

C. Diagnostic and Laboratory Test

1. Human Chorionic Gonadotropin (hCG) Test
 This is to check for the hormone hCG in blood or urine
 This also detects abnormally high levels of the hormone before treatment
 hCG levels are measured to determine if they fall and then disappear
2. Ultrasound Examination
 Uses high frequency sound waves to visualize the structures within the body
 This visualize a partial mole that includes some fetal tissue and membranes and a
complete mole that is composed only of enlarged villi but contains no fetal tissue
or membranes
3. Chest radiography
 This is used to diagnose conditions affecting the chest, its contents, and nearby
structures.
 This is also used to see whether the mole has spread to the lungs.
 4. Computed Tomography and Magnetic Resonance Imaging (MRI)
 To detect metastatic disease
5. Complete blood count, laboratory assessment of coagulation status and blood type and
screen or cross-match
 This is necessary in case a transfusion is needed
D. Risk Factors
- Maternal age older than age 35 or younger than age 20, previous molar pregnancy,
nutrition or diet, blood type and family history of molar pregnancy are the following
factors that may raise a woman’s risk of developing GTD

E. Pathophysiology

F. Nursing Diagnoses by Priority (5)

1. Fear related to the possible development of choriocarcinoma
2. Anticipatory grieving related to the loss of the pregnancy secondary to GTD
3. Deficient Knowledge Related to Lack of Knowledge about diagnostic and therapeutic
procedure, signs and symptoms of additional complications, dietary measures to
prevent infection and recommended follow-up care

G. Nursing Care Plan (3)

H. Nursing Management/ Intervention

 Monitor vital signs for an elevated temperature and pulse
 Teach deep breathing techniques to alleviate the pain. Use diversional activities if
possible.
 Administer all medications that is ordered
 Observe vaginal bleeding for excessive bleeding for excessive amount or foul odor
 Advise patient to do a contraceptive method within the period of monitoring the hCG
levels to avoid pregnancy for accurate monitoring.
 Monitor the hCG level and follow-ups.

I. Medical/ Surgical Management

 Medical Management
o Evacuation of the trophoblastic tissue of the mole
o Continuous follow-up of the patient to detect malignant changes of any
remaining trophoblastic tissue
 Surgical Management
o Vacuum Aspiration
 This uses aspiration to remove uterine contents through the cervix
  This procedure can be used after the last menstrual period (early first
trimester). It involves the use of a specially designed syringe to apply
suction.
o Curettage
 This is removal of tissue or aspiration within the uterus with an instrument
called a curette.
J. Drug Analysis
1. Methotrexate
Dactinomycin
 INCOMPETENT CERVIX
A. Description
 That is also called cervical insufficiency in which the cervix dilates prematurely and
therefore cannot hold a fetus until term.
 This is also the inability of the cervix to remain closed long enough during pregnancy
for the fetus to reach a maturity sufficient to survive.

B. Focus Assessment (Signs and Symptoms)

 A pink-stained vaginal discharge
 Rupture of membranes
 Discharge of the amniotic fluid
 Pelvic pressure sensation
 A new backache
 Mild abdominal cramps
 Light vaginal bleeding

C. Diagnostic and Laboratory Test

1. Sonogram/ Ultrasound
 Uses high frequency sound waves to visualize the structures within the body
 The ultrasonic waves deflect off tissues within the woman's abdomen, showing
structures of varying densities
2. Transvaginal ultrasound.
- This is to check if membranes are protruding through the cervix and to evaluate
the length of your cervix.
3. Pelvic exam.
- This inspects the vagina, cervix, fallopian tubes, vulva, ovaries, and uterus by the
physician. However, this will examine the cervix of the mother to see if the
amniotic sac has begun to protrude through the opening.
- This exam could identify that the mother has cervical insufficiency if the fetal
membranes are in your cervical canal or vagina, this indicates cervical
insufficiency.
4. Amniocentesis
- This is the insertion of thin needle through the abdominal ans uterine walls to
obtain a sample of amniotic fluid, which contains cast-of fetal cells and various
fetal products
- This will be ordered by the physician if fetal membranes are visible and an
ultrasound shows signs of inflammation but patient doesn’t have symptoms of an
infection,
 - This is also to to diagnose an infection of the amniotic sac and fluid which is
called chorioamnionitis.

D. Risk Factors
 Increased maternal age, congenital or endocrine development such as uterine
abnormalities and genetic disorders affecting a fibrous type of protein that makes up
your body's connective tissues (collagen) and cervical trauma such as might have
occurred with a D& C or traumatic delivery is probably often the cause.
E. Pathophysiology

F. Nursing Diagnoses by Priority (5)

G. Nursing Care Plan (3)

H. Nursing Management/ Intervention

 When the patient report about having a painless bleeding:
 Assess the her if she feels an intense pressure on her pelvis.
 Inspect and save pads that was used during bleeding to determine any clots or
tissues that already passed out.
 Monitor for the contractions and fetal heart tone of the baby to prepare for the birth of
the fetus.
 Teach patient on safe ways to relax
 If the patient gave birth prematurely and has a feelings of guilt, let the patient to talk
to someone to prevent patient from having mental illness
 Advise to patient’s significant other that the patient needs a great deal of support
 Advise the patient to refrain from doing restricting sexual activity or limiting certain
physical activities

I. Medical/ Surgical Management

 Medical Management
 Administration of Progesterone supplementation.
- A form of the hormone progesterone called hydroxyprogesterone caproate
(Makena) will be given weekly thru intramuscular during the patient’s second
and third trimester.
- This is for pregnant women to help lower the risk of preterm birth or giving
birth less than 37 weeks of pregnancy
 Repeated ultrasounds.
- This will be ordered by the physician every two weeks from 16 weeks through
24 weeks of pregnancy if the pregnant woman has a history of early premature
 birth or history that may increase the risk of having incompetent cervix to the
patient.
 Surgical Management
 Cervical Cerclage
 This is a surgical procedure to reinforce the cervix during pregnancy in
women with a history of a short cervix that uses synthetic tape or sutures.

J. Drug Analysis
Hydroxyprogesterone
Tocolytic- Terbutaline
 PLACENTA PREVIA

A. Description:
 It is the low implantation of the placenta and attachment of the placenta to the wall of
the uterus in a location that completely or partially covers the uterine outlet
 This occurs in four degrees:
1. Implantation in the lower rather than in the upper portion of the uterus
2. Marginal implantation
3. Implantation that occludes a portion of the cervical os
4. Implantation that totally obstructs the cervical os
 An increase in congenital anomalies in the fetus may occur if the low implantation
does not allow for optimal fetal nutrition or oxygenation

B. Focus Assessment (Signs and Symptoms)

 Bleeding that occurs in sudden, painless and bright red in the last half of the
pregnancy
 Bleeding that is associated with uterine contractions and abdominal pain.

C. Diagnostic and Laboratory Test

1. Apt or Kleihauer-Betke Test
 Used to detect wether blood is fetal or maternal origin
2. Urine specific gravity (SG)
 This measures the specific gravity of urine and another way of assessing fluid
volume adequacy
3. External Fetal Monitor
 This device is attached and used to listen or record the fetal heart sounds and
contractions through the mother's abdomen
4. Hematology Test
 Hemoglobin, hematocrit, prothrombin, partial thromboplastin, fibrinogen,
platelet count and type and cross-match are assessed to establish baselines, detect
a possible clotting disorder and ready blood for replacement if needed

5. Abdominal Examination
 The fetal head may be discovered to be nonengaged but this finding gives little
indication of how much of the placenta is obscuring the os and thus prevent the
head from engaging
6. Speculum Examination
  A device named speculum is used to look inside in the vagina and observe the
cervix.
 This is to rule out a source of bleeding such as ruptured varices or cervical
trauma and to establish the percentage of placenta covering the os
7. Vaginal Examination
 This is the actual investigation of dilation
 This is to determine whether placenta previa exists are done in an operating room
so that if hemorrhage does occur with the manipulation, the woman may be
immediately sections to remove the child and the bleeding placenta, contract the
uterus and save the both the woman and child
8. Sonogram/ Ultrasound
 Uses high frequency sound waves to visualize the structures within the body
 The ultrasonic waves deflect off tissues within the woman's abdomen, showing
structures of varying densities

D. Risk Factors
 Risk Factors could be because she had a baby, have scars on the uterus from
previous surgery such as cesarean deliveries, uterine fibroid removal, and dilation
and curettage, she had placenta previa in a previous pregnancy, a multiparous,
maternal age of 35 or older and uses cigarette and cocaine.

E. Pathophysiology

F. Nursing Diagnoses by Priority (5)

1. Fear related to outcome of pregnancy following episode of placenta previa bleeding
2. Anxiety related to unknown effects of bleeding and lack of knowledge of predicted
course of management
3.
4.
5.

G. Nursing Care Plan (3)

H. Nursing Management/ Intervention

 Allow woman to have immediate bed rest in a side lying position
 Assess:
 The starting time of bleeding
 The estimation of the amount of blood
 For accompanying pain
 The color of the blood
  On what she had done for the bleeding
 For the episodes of bleeding during pregnancy
 Wether she had prior cervical surgery for an incompetent cervix
 The duration of pregnancy
 Take vital signs to determine wether the symptoms of shock are present and do this
every 15 mins
 Monitor fetal heart sounds
 Allow patient to talk to someone about her fears
 Advise to patient’s significant other that the patient needs a great deal of support
 Provide a specific, accurate information about the condition of the fetus

I. Medical/ Surgical Management

 Medical Management
o Administration of Betamethasone
 to encourage maturity of fetal lungs
 Surgical Management
o Cesarean Delivery
 This is a surgical delivery of a fetus by an incision through the mother's
abdomen and uterus.
 This will be done because of the low implantation of the placenta

Mechanism Adverse Contraindi Nursing

Side Effects
of Action Effects cations Responsibilities
Generic This is a  weight gain  Red  Hypersen  Monitor patient’s
Name: corticosteroi  Burning, rash and sitivity to vital signs
Betamethasone d drug, itching, or inflame betametha  Assess for history
sometimes dryness of d skin sone of infections
Brand Name: called a the skin.  Skin  Systemic  Do not give live
Celestone, steroid that  Extremely sensitivi fungal inf virus vaccines
Celestone reduces the thick hair ty to ection with
Soluspan, amount of growth on sunlight  Untreated immunosuppressi
Betaject, inflammatory unusual serious ve doses of
Betamethasone chemicals areas of the infections corticosteroids.
IM/PO your body body  Administr  Advise patient to
makes. They  Red bumps ation of avoid exposure to
Dosage: also reduce around the live, atten infections so that
4 mg/ml your body’s mouth. uated vac ability to fight
natural  Loss of cines is infections is
Frequency: immune natural skin contraindi reduced.
BID response, color. cated in  Advise patient to
which helps  Thinning of patients report unusual
Route: to control the skin. receiving weight gain,
IM inflammation immunos swelling of the
. uppressiv extremities,
Drug e doses of muscle weakness,
Classification: corticoste black or tarry
Corticosteroids roids stools, fever,
prolonged sore
throat, colds or
other infections,
worsening of
original disorder
J. Drug Analysis
Resources:
Mckinley, E., James, S., Murray, S. and Ashwill, J. (2013). Matenal – Child Nursing

Mckinley, E., James, S., Murray, S. and Ashwill, J. (2005). Matenal – Child Nursing

London, M., Ladewig, P., Ball, J. and Bindler, R. (2007). Fundamentals of Maternal and Child
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