| Assessment/Observations | Possible Problem | Nursing Care Plan/Implementation |
|---|
| First Trimester |
| Fluid-Gas Transport |
| a. Cramping—with or without bleeding or passage of tissue | - Abortion (before 24 weeks): threatened, imminent, incomplete, septic
| - Bedrest, sedation, avoid coitus—if threatened; bedrest, start IV fluids and draw blood for laboratory work: CBC, type/crossmatch, electrolytes, platelets, HCG levels
|
| b. Passage of tissue (products of conception; grapelike vesicles) or brown spotting; fundus too high for gestational age; blood pressure elevated. Often associated with hyperemesis gravidarum and preeclampsia | | - Vital signs q5–15 min, prn
|
| c. Severe pain, shock out of proportion to amount of overt blood; shoulder-strap pain ( Kehr’s sign ), a “referred pain” that indicates intra-abdominal bleeding (or rupture of ovarian cyst); amenorrhea of 6–12 weeks | | - Save all pads or tissue passed through vagina for physician evaluation
No rectal or vaginal examination until physician is present
|
| d. Malodorous discharge; hyperthermia and chills; tender abdomen | - Septic abortion (selfinduced or “criminal”)
| - Take complete history, if possible Convulsion precautions if hypertensive
|
| e. Ecchymosis or bleeding—with a history that includes any or all of the following: had symptoms of pregnancy, but they subsided; pregnancy test negative; uterine size diminishing; no FHR | | - Emotional support for loss of pregnancy (through nurse’s manner, tone of voice, touch, use of woman’s name; keep her informed of what is happening); oxygen, prn
|
| Second Trimester |
| Fluid-Gas Transport |
| a. Cramping; passage of products of conception | | - Same as for first trimester
|
| b. Labor—cervical changes, “show” | | - See physician immediately for possible cerclage
|
| c. Prolonged nausea and vomiting; unexplained hypertension or preeclampsia; passage of dark blood or grapelike vesicles; absent FHRs; excessive fundal height for gestation | | - Maintain hydration; assess for dehydration; refer to physician
|
| Sensory-Perceptual |
| a. Preeclampsia/eclampsia | With increased severity: renal failure, circulatory collapse, stroke, coagulation defects (DIC); abruptio placentae; convulsions | Pharmacological management of hypertension (see Chapter 6. Physiological Integrity) |
- Assessment: hypertension first noted after 24 weeks; followed by increased proteinuria
- Symptoms: blurred or double vision; pain: headache, epigastric (late sign)
- Signs: BP ≥160/110; 3+ proteinuria
- Edema: facial, digital; pulmonary
- Oliguria
- Hyperreflexia
| | Convulsion precautions: - Emergency tray at bedside
- Oxygen/suction
- Start IV
- Padded siderails
- Limit environmental stimulation
- Constant observation
- Deep tendon reflexes
- Daily weight
- I&O—strict
- Note any complaints and changes
- Prepare for lab work (type and crossmatch, CBC, platelets, BUN and creatinine, uric acid, SGOT, SGPT)
|
| b. Convulsions in absence of hypertension, proteinuria, or facial edema | Stroke, epilepsy, drug toxicity; intracranial injury; diabetic complications; encephalopathy | Convulsion care:  Oxygen/mask; drugs (Valium, magnesium sulfate IV)- Observe:
- Uterine tone, FHR, fetal activity
- Signs of labor
- Emotional support for woman and family
|
| Third Trimester |
| Fluid-Gas Transport |
a. Bleeding: painless, bright red, vaginal
- Contractions or uterine tone normal
| Placenta previa | No vaginal examination - Apply fetal monitor; assess for labor
 Position: semi-to high Fowler’s Ultrasound to verify placental location As for placenta previa;- position : Sims’ Prepare for possible emergency cesarean delivery
|
b. Pain: abdomen rigid and tender to touch
- Increased uterine tone; signs of shock disproportionate to visible blood loss; may have loss of FHTs; associated with: preeclampsia, multiparity, precipitous labor, oxytocin induction, trauma, cocaine use
| Abruptio placentae |