Abruptio Placentae is a medical condition characterized by detachment of the placenta from the wall of the uterus (womb) inside before delivery, either in whole or in part. The placenta is the structure that forms during pregnancy to provide the necessary nutrients for the growth of the baby. When the placenta is torn, it can decrease the supply of oxygen and nutrients to the baby and cause severe bleeding in the mother. Symptoms include abdominal pain, back pain, frequent uterine contractions and vaginal bleeding. In most cases, the exact cause of abruptio placentae is unknown. However, factors, such as smoking, alcohol consumption, cocaine, trauma to the abdomen, hypertension and a history of childbirth that much can cause abruptio placentae. The treatment depends on how long the pregnancy has been running. If the baby is not yet near the time of delivery, the mother should be closely monitored in mild cases and in some cases, be given intravenous fluid therapy or blood transfusion. In severe cases where placental disruption cause life-threatening bleeding mother and fetus, or when the baby is close to the time of delivery, the mother will require immediate delivery is usually done by Caesarean section.
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Nursing Diagnosis and Interventions
Nursing Diagnosis : Ineffective Tissue perfusion (peripheral)
Definition : oxygen depletion resulting in the failure of delivery of nutrients to the tissues at the capillary level.
Defining characteristics :
- Changes in sensation.
- Changes in skin characteristics.
- Changes in blood pressure in the extremities.
- Pale skin when the elevation of the leg.
- Changes in skin temperature.
- Weak or absent pulse.
- Circulation status.
- Fluid balance.
Expected outcomes :
After nursing action for 3x24 hours the client is able to :
1. Demonstrate the circulation status which is characterized by :
- Systolic and diastolic pressure in the normal range.
2. Fluid balance can be maintained, as evidenced by :
- normal blood pressure
- skin turgor ; not dry
Interventions :
- Perform a comprehensive assessment of the peripheral circulation.
- Monitor fluid status.
- Monitor vital signs.
- Monitor cerebral perfusion pressure.
- Monitor fluid intake and output.
- Record the patient's response to stimuli.
- Position the patient in semi-Fowler's position.
- Instruct family to observe if there are lesions or skin lacerations.
- Use gloves for protection.
- Collaboration intravenous administration.
- Encourage oral input.
- Set the possibility of transfusion.
- Preparation for transfusion.
- Teach the patient / family tenghindari extreme temperature of the extremities.
- Encourage the patient to report signs and symptoms caused.
- Encourage the patient or family to check the skin every day to determine changes in skin integrity.