Assessment Nursing Diagnosis Planning Intervention Rationale Core Competencies

Objective: Deficient Fluid Short Term: Monitor Vital Signs To obtain baseline data Safe and quality nursing care
- Systolic=70-80 Volume related to After 4 hours of NI,
mmHg Active Blood Loss the pt will Assess color, odor, Provides information Safe and quality nursing care
- Pallor Secondary to verbalize consistency and about active bleeding
- Bradycardia Disrupted Placental understanding of amount of vaginal versus old blood, tissue
- Patient Implantation causative factors. bleeding; weigh loss and degree of blood
unresponsive Long Term: pads loss
- Active bleeding After 4 days of NI,
- Patient has the pt will Provides information Safe and quality nursing care
placenta previa maintain fluid Assess hourly about maternal and
in pregnancy volume at a intake and output. fetal physiologic
functional level compensation to blood
AEB individually loss
adequate urinary
output and stable Detecting increased in Safe and quality nursing care
vital signs. Assess abdomen for measurement of
tenderness or abdominal girth
rigidity- if present, suggests active
measure abdomen abruption
at umbilicus
Assess SaO2, skin Safe and quality nursing care
color, temp, Assessment provides
moisture, turgor, information about blood
capillary refill vol., O2 saturation and
(specify frequency) peripheral perfusion

Provide Safe and quality nursing care

supplemental O2 as Intervention increases
ordered via face available O2 to saturate
mask or nasal decreased hemoglobin
cannula @ 10-12
L/min.

Initiate IV fluids as Collaboration and teamwork

ordered (specify For replacement of fluid
fluid type and rate). vol. loss

Position Pt. in Safe and quality nursing care

supine with hips Position decreases
elevated if ordered pressure on placenta
or left lateral and cervical os. Left
position. lateral position improves
placental perfusion
Assessment Nursing Diagnosis Planning Intervention Rationale Core Competencies
Objective: Decreased cardiac After 4 hours of Evaluate client To assess for signs of Safe and quality nursing care
- Systolic=70-80 output related to effective nursing reports and poor ventricular
mmHg altered myocardial intervention, the evidence of function and pending
- Pallor contractility patient will extreme fatigue, cardiac failure
- Bradycardia demonstrate intolerance for
- Patient decreased activity, sudden or
unresponsive episodes of progressive weight
- Active bleeding dyspnea and gain, swelling of
dysrhythmias. extremities and
progressive
shortness of breath Provides baseline for
comparison to follow Safe and quality nursing care
Monitor vital signs
After 12 hours of trends and evaluate
effective nursing response to
intervention, the interventions
patient display
hemodynamic
stability Decreases oxygen Safe and quality nursing care
consumption and risk of
Keep client on bed
decompensation
or chair rest in
position of comfort.
May raise legs to 20
 to 30 degrees in
shock situation To note effectiveness of
medications Safe and quality nursing care
Monitor cardiac
rhythm
continuously
To reduce anxiety Health education

Encourage
relaxation
techniques

Assessment Nursing Diagnosis Planning Intervention Rationale Core Competencies

Objective: Ineffective tissue After 4 hours of Note customary For comparison with Safe and quality nursing care
- O2 sat=70-80% perfusion related effective nursing baseline data (usual current findings
- Apnea to decreased HgB intervention, the BP, weight, lab
- Hgb=10.7g/dl concentration in patient will values)
blood & demonstrate
hypovolemia increased tissue Determine To identify alterations Safe and quality nursing care
Secondary to perfusion presence of from normal
placenta previa dysrhythmias
After 8 hours of To identify / determine Safe and quality nursing care
effective nursing Perform blanch test adequate perfusion
interventions, the
patient will have a To determine presence Safe and quality nursing care
normal peripheral Check for Homan’s of thrombus formation
blood circulation. Sign
To lessen O2 demand Management of
Encourage quiet & resources and environment
restful environment
To promote circulation Safe and quality nursing care
Elevate HOB

Encourage use of
To decrease tension Health education
relaxation
 techniques level

Assessment Nursing Diagnosis Planning Intervention Rationale Core Competencies

Subjective: Acute Pain related After 30 minutes Monitor vital signs To provide baseline data Safe and quality nursing care
The patient to to 1 hour of of patient
reported presence of ischemia effective nursing
To promote non
pain intervention, the Provide comfort Management of
pharmacological pain
measures, quiet resources and environment
patient will have
management
reduced pain environment and
calm activities

After 2 hours of
effective nursing
Encourage use of To distract attention and Health education
interventions, the
relaxation reduce tension
patient’s pain will
techniques such as
be alleviated
focused breathing

Encourage Health education

diversional To distract attention and

activities. reduce tension

Administer To alleviate pain Collaboration and teamwork

analgesics as
prescribed

Assessment Nursing Diagnosis Planning Intervention Rationale Core Competencies

Objective: Risk for fall related After 4 hours of establish rapport to promote cooperation Communication
- Systolic=70-80 to decreased blood effective nursing
mmHg pressure intervention, the monitor vital signs to have a baseline data Safe and quality nursing care
- Pallor patient will have a
- Bradycardia modified keep the side rails to protect from falling Health education
- Low blood environment as of the bed raised out of bed
pressure indicated to
- Patient enhance safety remind client to to prevent injury Health education
unresponsive walk slowly, rest
- Active bleeding After 8 hours of adequately
effective nursing between intervals
interventions, the of walking use
patient will be free effective lighting
of injury for continuous Health education
inform pt’s so not monitoring and
to leave her in the guidance to the client
bathroom

Assessment Nursing Diagnosis Planning Intervention Rationale Core Competencies

Objective: Impaired Gas Short Term:
- O2 sat=70-80% exchange related After 4 hours of 1. Monitor vital 1. To note any Safe and quality nursing care
- apnea to decreased effective nursing signs deviation that may
pulmonary interventions, the indicate further
perfusion patient will have progression of Safe and quality nursing care
associated with an improved illness
obstruction of breathing pattern.
pulmonary arterial 2. Assess for 2. Restlessness is an
blood flow by the changes in early sign of
embolus and orientation and hypoxia. Mentation
vasoconstriction behavior. gets worse as
Long Term: hypoxia increases Safe and quality nursing care
After 8 hours of due to lack of blood
effective nursing supply to the brain.
interventions,
patient will
demonstrate a 3. Pulse oximetry is

normal depth, rate 3. Place the useful in detecting

and pattern of patient on changes in Safe and quality nursing care

respirations. continuous oxygenation. Oxyge

pulse oximetry. n saturation should

be maintained at
 90% or greater.

4. Assess skin 4. Lack of oxygen Safe and quality nursing care

color for delivery to the
development of tissues will result in
cyanosis, cyanosis. Cyanosis
especially needs treated
circumoral immediately as it is
cyanosis. a late development
in hypoxia.

5. Early supplemental
Safe and quality nursing care
oxygen is essential
in all trauma
patients since early
Safe and quality nursing care
mortality is

5. Provide associated with

supplemental inadequate delivery

oxygen, via of oxygenated blood

100% O2 non- to the brain and

rebreather vital organs.

 mask.

6. Promotes better
lung expansion and
improved gas Safe and quality nursing care
exchange.

6. Position patient 7. Promotes alveolar

with head of expansion and
bed 45 degrees prevents alveolar
(if tolerated). collapse.
Splinting helps
7. Assist patient reduce pain and
with coughing optimizes deep
and deep breathing and
breathing coughing efforts.
techniques
(positioning,
incentive
spirometry,
8. Even simple
frequent
activities, such as
position
bathing, can
changes,
 splinting of the increase oxygen
chest). consumption and
cause fatigue.

8. Pace activities
and provide
rest periods to
prevent fatigue.