Primary Nursing Diagnosis

Fluid volume deficit related to blood loss OUTCOMES. Fluid balance; Hydration; Circulation status

INTERVENTIONS. Bleeding reduction; Blood product administration; Intravenous therapy; Shock management

H PLANNING AND IMPLEMENTATION Collaborative

Management of a patient with placenta previa depends on the admission status of the mother and the fetus, the amount of blood loss, the likelihood that the bleeding will subside on its own, and the gestational age of the fetus. If both the mother and the fetus are stable and the fetus is immature (less than 37 weeks), delivery may be put off and an intravenous (IV) infusion started with lactated Ringer's solution. In addition, the patient is maintained on bedrest with continuous EFM. Closely monitor the fetal heart rate. If any signs of fetal distress are noted (flat variability, late decelerations, bradycardia, tachycardia), turn the patient to her left side, increase the rate of IV infusion, administer oxygen via face mask at 10 L/min, and notify the physician. Once the bleeding has ceased for 24 to 48 hours, the patient may be discharged to her home on bedrest before delivery. This conservative treatment gives the preterm fetus time to mature. If the patient is in labor and a marginal placenta previa is present, the physician allows her to labor and deliver vaginally, with careful surveillance of maternal and fetal status throughout the labor. Postpar-tum, the patient will require oxytocics to prevent hemorrhaging, owing to the poor ability of the lower uterine segment to contract.

If fetal distress is present or if the patient has lost a significant amount of blood, an immediate cesarean section and, possibly, blood transfusions are indicated. If the patient delivers (vagi-nally or by cesarean), monitor her for postpartum hemorrhage because contraction of the lower uterine segment is sometimes not effective in compressing the uterine vessels that are exposed at the placental site. Although medication is not given to treat a previa, pharmacologic treatment may be indicated to stop preterm labor (if it is occurring and if bleeding is under control), enhance fetal lung maturity if delivery is expected prematurely, or prevent Rh disease, if the patient delivers.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Magnesium sulfate

4-6 g IV loading dose, 1-4 g/hr of IV maintenance

Central nervous system (CNS) depressant

Effective tocolytic, has fewer side effects than beta-adrenergic drugs; administered only if bleeding is under control and preterm labor is evident

Betamethasone (Celestone)

12 mg IM q 24 hr X 2 doses

Glucocorticoid

Hastens fetal lung maturity; given if delivery is anticipated between 24 and 34 wk

RhD immunoglobin (RhoGAM)

120 |jg (prepared by blood bank)

Immune serum

Prevents Rh isoimmunizations in future pregnancies; given if mother is Rh negative and infant is Rh positive

Independent

If the patient is actively bleeding, and mother and fetus are stable, maintain the patient on bedrest in the lateral position (preferably left lateral) to maximize venous return and placental perfusion.

736 Pneumocystis carinii Pneumonia

Because the patient may be on bedrest for an extended period of time, comfort can be increased with back rubs and positioning with pillows. Provide diversional activities and emotional support. The nurse should make every attempt to explain the condition, treatment, and potential outcomes to the patient. Often, if a preterm delivery is unavoidable, a special care nursery nurse comes in and discusses what the mother can expect to happen to her infant on admission to the neonatal intensive care unit.

0 0

Post a comment