ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Data  Deficit fluid  After 8 hours Pre-operative Care  After 8 hours of
volume related of nursing Independent: nursing intervention
The patient was to excessive intervention the patient was
conscious but looks blood loss. the patient  Assess and document the  To know the actual unable to normalize
pale. will blood loss blood loss and to her blood volume
normalize determine the and show unstable
her blood appropriate treatment vital sign. She was
V/S taken as follows: volume, needed by the patient. announced dead 3
show October 2013 at
BP: 80/60mmHg improvemen 11:45 pm due to
HR: 71 bpm t in her fluid  Review the records and  This will help in retained placenta,
RR: 12 cpm balance as note certain conditions determining the hypovolemic shock
evidenced such as retained placental management of the secondary to severe
by a good fragments, any laceration, situation thus anemia.
capillary abruptio placenta, etc. preventing further
refill and complications.
stable vital
signs.
 Monitor the Vital Signs and  Increased heart rate,
check for capillary refill. low blood pressure,
cyanosis, delayed
 capillary refill indicates
hypovolemia and
impending shock.
Decrease fluid volume
of 30-50% will reflect
changes in the blood
pressure.

 Massage the uterus.  To help expel clots of

blood and it is also
used to check the tone
of the uterus and
ensure that it is
clamping down to
prevent excessive
bleeding.

 Place the mother in  Encourages venous

Trendelenberg position. return to facilitate
circulation, and prevent

 Provide comfort measure
like back rubs, deep
breathing. Instruct in
relaxation or visualization
exercises.
Collaborative:
 Start 1 or 2 IV infusion(s) of 
isotonic or electrolyte fluids
with an 18-gauge catheter
or via a central venous line.
Administer fresh whole
blood or other blood
products (e.g., platelet
concentrate, plasma,
cryoprecipitate) as
indicated
further bleeding.
 Promotes relaxation
and may enhance
patient’s coping
abilities by refocusing
attention.
This is important for
rapid or multiple
infusions of fluids or
blood products to
increase circulating
volume and enhance
clotting. Note: Each
unit of whole blood
increases the
hematocrit level by
three percentage
 points.

 Administer medication as  To promote contraction

indicated (e.g Pitocin, and prevents further
Methergin) bleeding.

Post Operative Care

Independent:

 Monitor the vital signs  To rule out for shock.

(pulse, blood pressure,
respiration) every 30
minutes for the next 6
hours or until stable. 

 Palpate the uterine fundus.  To ensure that the

uterus remains
contracted.
 Check for excessive lochia.  To determine if the

Collaborative:
 Continue infusion of IV
fluids as indicated.
 Transfuse blood as
indicated.
amount discharged is
still within the normal
limits.
 To maintain the
patient’s hydration,
electrolyte and blood
sugar level.
 To replace the blood
that is lost through
surgery and the
patient’s bleeding.