Nursing Care Plan for Acute Pain related to Placental Abruption

Nursing Care Plan for Placental Abruption

Definition

Placental Abruption is the release of the placenta from the insertion prematurely.

Etiology

Not known for sure. Possible predisposing factors are chronic hypertension, external trauma, short umbilical cord, uterine sudden decompression, anomalies or uterine tumors, nutritional deficiency, smoking, alcohol consumption, the abuse of cocaine, as well as obstruction of the inferior vena cava and ovarian veins.

Clinical manifestations

• History : usually in the third trimester bleeding, vaginal bleeding blackish color are few and without pain until accompanied by abdominal pain, tense uterus, vaginal bleeding that much, shock, and intrauterine fetal death.
• Physical examination : vital signs can be normal to show signs of shock.
• Obstetric examination : uterine tenderness and tension, fetal parts difficult to assess.
• Difficult to assess the fetal heart rate or no, amniotic fluid is reddish because of mixed blood.

Diagnostic tests

• Laboratory tests Blood : hemoglobin, hematocrit, platelets, prothrombin time, clotting time, partial thromboplastin time fibrinogen levels , and plasma electrolytes.
• KTG to assess fetal well-being.
• Ultrasound to assess placental location gestational age, and state of the fetus.

Complication
Depending spacious detached placenta and placental abruption duration lasts. Maternal complications are bleeding, consumptive coagulopathy (fibrinogen levels less than 150 mg % and increased fibrin degradation products), oliguria, renal failure, fetal distress, fetal death, and uteroplacental apoplexy (Couvelaire uterus). If the fetus can be saved, complications can occur asphyxia, low birth weight, and respiratory failure syndrome.


Nursing Diagnosis and Interventions :

Acute pain

Definition : Acute pain is a sensory and emotional experience unpleasant that arise as a result of tissue damage to the actual and potential or described in such a way. (International Association For The Study of Pain ) ; sudden onset or slow from mild to severe intensity at the end of which can be anticipated or predicted and lasted less than 6 months.

Defining characteristics :
Subjective Data

• Verbalize or report pain with cues.

Objective Data

• Position to avoid pain.
• Expressive behavior (eg, restlessness, moaning, crying, excessive vigilance, sensitive to stimuli and took a deep breath).
• Face mask (pain).
• Behavior maintain or condescension.
• Evidence that pain can be observed.
• Sleep disorders.

NOC :
Level of pain :
1 : No
2 : Lightweight
3 : Medium
4 : Weight
5 : Very severe

Pain control :
1 : Never
2 : Rarely
3 : Sometimes
4 : Often
5 : Always

The comfort level
After the act of nursing for 3 x 24 hours expected patient would say the pain is reduced or resolved , with expected outcomes :

• The patient did not show facial expressions of pain .
• The patient did not look nervous.
• The patient will report pain and duration of pain episodes .
• The patient did not moan and cry .

Patients maintain the level of pain on a scale of 2/5 , with the indicator :
1 : No
2 : Lightweight
3 : Medium
4 : Weight
5 : Very severe

NIC :

• Conduct a comprehensive assessment of pain include the location, characteristics, onset and duration, frequency of quality, intensity or severity of pain and prespitasinya factor.
• Observation of non-verbal cues of discomfort, especially there are those who are unable to communicate effectively.
• Include in particular oabat patient discharge instructions should be in drinking, frequency of administration, possible side effects, drug interaction possibilities, special vigilance, while taking the drug (limitation of physical activity, dietary restrictions) and name of the person who should be contacted when a stubborn pain.
• Adjust the frequency of the dose as indicated by assessment of pain include the location, characteristics, onset and duration, frequency of quality, intensity or severity of pain and the precipitation factor.
• Manage pain with opioid administration scheduled.
• Providing analgesic before performing the procedures that cause pain.
• Monitor vital signs before and after the first analgesic.

Health Education :

• Provide information about pain , such as the cause of pain, how long it will last, and the anticipation of discomfort as a result of the procedure.
• Non- pharmacological techniques taught before, after and if possible diving activities that cause pain occurs or increases ; and concurrent use of other pain relief measures.
• Present near the patient to meet the needs of comfort and other activities to meet the needs of comfort and other activities to help relaxation, includes the following:

· Make changes position , masasae back and relaxation.

· Change lenen bed, if necessary.

· Provide care with no rush, with attitudes that support.

· Involve patients in decisions regarding nursing activities.

• Help the patient to focus more on activities, not on the pain and discomfort with the transferor through television, radio, tape and interaction with visitors.
• Control of environmental factors that can affect the patient's response terrhadap discomfort (eg, room temperature, lighting and noise).