Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Vaginal bleeding  Monitor *Monitored vital signs *Increase heart rate, After doing all the
“Ma’am masakit po ang (Lochia) secondary vital signs every four hours low blood pressure, interventions, the
tahi ko. to normal delivery  Encourage (Hospital’s rule) and delayed capillary bleeding decreased
Objective: the mother *Encouraged the refill indicates by 20%. I assessed
*the patient is awake to breast mother to breastfed hypovolemia and the improvement of
when I arrived. feed *Administered the impending shock. the intervention that I
*Skin is quite pale.  Regular mother in changing her Decrease fluid have formulated by
*There is a presence of change of diaper volume of 30-50% checking the blood in
Linea Negra. diaper *Assisted the mother in will reflect in the the next diaper
*The patient is  Maintain a maintain bed rest with blood pressure. change.
experiencing a heavy bed rest with an elevation of the legs *Breastfeeding
blood flow in her vagina. an elevation by 20-39o and the trunk Stimulates the
of the legs horizontal release of oxytocin,
by 20-10o *Educated the mother which triggers
and the about lochia uterine contractions.
trunk discharges. 8Regular change of
horizontal diaper prevents your
 Educate the skin from having
mother rashes or any skin
about lochia irritation and
discharges. promotes good
hygiene.
*The position
increases venous
return, making sure a
greater availability of
blood to the brain
and other vital
organs and blood
may decreased with
the bed rest
* Educating your
client is necessary
because it is her right
to know her
condition. Aside
from that, it also
clears all the
misconception of the
mother in connection
with her condition.
Assessment Diagnosis Planning Interventions Rationale Evaluation

Objective: The baby feels or >Tell the mother to *Told the mother to *Crying may indicate After being cradled
*The baby is awake experiencing start breast feeding. breastfeed. that the baby is by the mother, the
*the baby’s skin is discomfort. >Check the boots, *Checked the booties, hungry. baby stopped crying.
pinkish in color gloves, and the gloves, and the bonnet *Cradling the baby
*Baby has a few bonnet of the baby if *Encouraged the stimulates sleepiness
presences of rash on her there are run out mother to cradle the of the baby and they
eyes and upper and lower fibers. baby feel comfort while
extremities. >Encourage the *Improved the being cradled.
*Baby is crying heavily mother to cradle the ventilation in the are of *The area is hot so
baby. the baby by fanning at improving
>Improve the her. ventilation may
ventilation in the *Checked the vital provide comfort for
area signs of the baby the baby.
>Check vital signs *Educated the mother *Checking vital signs
of the baby. about the possibilities is necessary. Its
why her baby is results can help
>Educated the experiencing determining why the
mother about the discomfort. baby is experiencing
possibilities why the any discomfort.
baby is feeling or *Educating the
experiencing mother is important,
discomfort. it helps them calm
and think that their
baby is okay that she
is only experiencing
discomfort.