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Case Study

This nursing care plan is for a 30-year-old pregnant woman at 32 weeks gestation who is experiencing bright red vaginal bleeding. On examination, her vitals are stable and the fetal heart rate is normal. She is likely experiencing placenta previa, where the placenta covers the cervix, as the bleeding is painless and there are no other risk factors for placental abruption. An ultrasound will be done before a vaginal exam to avoid inducing more bleeding. Given the gestational age and stability of mother and baby, expectant management is the best approach for now.

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Darwin Quirimit
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58 views2 pages

Case Study

This nursing care plan is for a 30-year-old pregnant woman at 32 weeks gestation who is experiencing bright red vaginal bleeding. On examination, her vitals are stable and the fetal heart rate is normal. She is likely experiencing placenta previa, where the placenta covers the cervix, as the bleeding is painless and there are no other risk factors for placental abruption. An ultrasound will be done before a vaginal exam to avoid inducing more bleeding. Given the gestational age and stability of mother and baby, expectant management is the best approach for now.

Uploaded by

Darwin Quirimit
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

NURSING CARE PLAN

Patient’s Name: MRS. ELLE SORIANO Age & Gender: 26/FEMALE Chief Complaint:
Name of Student Nurse: QUIRIMIT, DARWIN N. Birthdate: January 1, 1992
Admitting Diagnosis: Level/Block/Group: Level 2
Address: 123 POBLACION, MANGALDAN, PANGASINAN
Hospital/Area: OB RLE
Date of Confinement: February 21, 2022 Clinical Instructor: MRS. B.M.S & MRS. K.L.U Date: February 21, 2022
CASE:
A 30-year-old G5P4 woman at 32 weeks’ gestation complains of significant bright red vaginal bleeding. She denies
uterine contractions, leakage of fluid, or trauma. The patient states that 4 weeks previously, after she had engaged in
sexual intercourse, she experienced some vaginal spotting. On examination, her blood pressure is 110/60 mm Hg,
heart rate (HR) is 80 beats per minute (bpm), and temperature is 99°F (37.2°C). The heart and lung examinations are
normal. The abdomen is soft and uterus nontender. Fetal heart tones are in the range of 140 to 150 bpm.
This patient is experiencing antepartum vaginal bleeding (bleeding after 20 weeks’ gestation). Because of the painless
nature of the bleeding and lack of risk factors for placental abruption, this case is more likely to be placenta previa,
defined as the placenta overlying the internal os of the cervix. Placental abruption (premature separation of the
placenta) usually is associated with painful uterine contractions or excess uterine tone. The history of postcoital
spotting earlier during the pregnancy is consistent with previa because vaginal intercourse may induce bleeding. The
ultrasound examination is performed before a vaginal examination because vaginal manipulation (even a speculum
examination) may induce bleeding. Because the patient is hemodynamically stable, and the fetal heart tones are
normal, expectant management is the best therapy at 32 weeks’ gestation (due to the prematurity risks). If the same
patient were at 35 to 36 weeks’ gestation, delivery by cesarean section would be prudent.
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUJECTIVE:

OBJECTIVE:

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