Ateneo De Zamboanga University College of Nursing Clinical Assignment Menchievie S.

Cantere, BSN-II C Module 5a- Mat (Nursing Care Plan for Post-partal Hemorrhage) Clinical Area: Boalan, Lying in Maternity Center Nursing Diagnosis Goals of care/ Outcome Criteria After an 8 hours of nursing interventions , the patient will demonstrate adequate perfusion and stable vital signs. Nursing Intervention

Cues

Implementation Evalutaion

Subjective Cues: Halos ilang linggo na akung nakapanganak pero malakas pa rin ang pagdurugo ko

Risk for ineffective tissue perfusion related to hemorrhage.

>Monitor amount of bleeding by weighing all pads. Rationale: To measure the amount of blood loss. >Frequently monitor vital signs. Rationale: Early recognition of possible adverse effects allows for prompt intervention. > Massage the uterus. Rationale: To help expel clots of blood and it is also used to check the tone of the uterus and

-Collect the pads that being used by the patient.

After 8 hours of nursing interventions, the patient was able to demonstrate adequate perfusion and stable vital signs.

(I m still bleeding heavily after weeks of giving birth) as verbalized by the patient. Objective Cues: > Restlessness > Confusion >Irritability > V/S taken as follows: T: 36.8 P: 105

-Took and record vital signs.

-Massaged the uterus. -Observed if it was firm or not.

R: 24 Bp: 100/70

ensure that it is clamping down to prevent excessive bleeding. >Place the mother In Trendelenberg position. Rationale: Encourages venous return to facilitate circulation, and prevent further bleeding. > Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises Provide diversional activities. Rationale: Promotes relaxation and may enhance patient s coping abilities by refocusing attention. Collaborative: >Administer oxygen as indicated.

-Encouraged mother to position into Trendeleberg Position. -Placed mother in Trendeleberg position. -Assisted mother to position on it.

-Provided comfort measures to the client. -Instructed her to use that kind of comfort measures.

-Administered oxygen as indicated.

Rationale: To supply adequate oxygen to the fetus and mother and prevents further complication. >Administer medication as indicated (e.g Pitocin, Methergin) Rationale: To promote contraction and prevents further bleeding.

-Adminitered medication as indicated.

Clinical Sign: _________________

Reference: NursingCrib.com