ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:
Deficient fluid After 8 hours of nursing INDEPENDENT: After 8 hours of
“Dinudugo ako, volume intervention the patient will  Monitor vital signs, compare  Changes in blood nursing
humuhilab ang (isotonic) demonstrate improved fluid with patient’s normal or pressure may be intervention the
tiyan ko kagabi related to balance as evidenced by previous readings. Take blood used for rough patient was able
pa, 12 linggo na excessive stable vital signs, good skin pressure when possible. estimate of blood to
ang blood loss. turgor, and prompt capillary  Note patient’s individual loss. demonstrate
ipinagbubuntis refill. physiological response to improved fluid
ko” bleeding such as changes in  Symptomatology balance as
mentation, weakness, may be useful in evidenced by
restlessness, and pallor. gauging severity stable vital signs,
OBJECTIVE: or length of good skin turgor,
bleeding episode. and prompt
 Delayed Worsening of capillary refill.
capillary refill  Measure central venous symptoms may
 Restlessness pressure (CVP), if available. reflect continued
 Changes in bleeding or
mentation inadequate fluid
replacement.
 V/S taken as
follows  Monitor intake and output  Reflects
(I&O), and correlate with circulating volume
T: 36.9 ˚C weight changes. and cardiac
P: 90  Maintain bed rest. Schedule response to
R: 19 activities to provide bleeding and fluid
BP: 110/ 70 undisturbed rest periods. replacement.

 Provides
DEPENDENT: guidelines for
 Administer fluids as indicated. fluid replacement.

 Activity increases
intra-abdominal
pressure and can
 Administer vitamin K. predispose to
further bleeding.

 Fluid replacement
 Monitor Hb, Hct, RBC count. with isotonic
solutions
 depends on the
degree and
duration of
bleeding.
 Promotes hepatic
synthesis of
coagulation
factors to support
clotting.
 Aids in
establishing blood
replacement
needs and
monitoring the
effectiveness of
therapy.