NURSING CARE PLAN

Assessment NURSINGDIAGNOSIS OBJECTIVES/EVALUATION NURSING Rationale Evaluation

CRITERIA INTERVENTIONS
Subjective: Risk for STO:
bleeding r/t STO: Dx: (Goal Met)
No statements pregnancy or  Assess for  identifying risk
were postpartum Within 30 minutes - 1 patient’s risk factors help the Within 30 minutes - 1
verbalized by complications hour of effective nursing factors while nurse to hour of effective
the patient interventions. The patient noting medical conduct proper nursing interventions.
will be able to: diagnosis that and appropriate The patient identified
Objective: may lead to procedures the appropriate
a) Identify bleeding  Determining methods to provide
Lacerations appropriate  Identify pregnancy- relief from pain. How
brought about methods to pregnancy- related factors she can control it,
by forceful provide relief related factors such as verbalized relief from
uncoordinated from pain. as indicated lacerations pain and discomfort
pushing b) Demonstrate use  Monitor during vaginal
of relaxation skills perineum in a delivery can LTO:
and diversional postpartum reduce the risk (Goal Met)
activities as client, for postpartum
indicated. including bleeding After 2-3 days of
c) verbalize relief wounds,  To identify nursing intervention,
from pain and dressings or active blood loss the patient was free of
discomfort. tube in a client as hemorrhage signs of active
with trauma may occur bleeding(hemorrhage)
LTO:  Assess vital  Vital signs are or excessive blood loss
signs, including important in as evidenced by stable
Within 2-3 days of nursing blood assessment vital signs, skin and
interventions, the patient pressure, that may mucous membranes
will: pulse, and prompt free of pallor and was
a) free of signs of respirations, detection of able to engage
active also the level delayed inappropriate
bleeding(hemorrh of and recovery or behaviors to prevent
 age) or excessive discomfort adverse events bleeding
blood loss as experience  This can help
evidenced by  Note client’s identify
stable vital signs, report of pain bleeding into
skin and mucous in specific tissues, organs
membranes free areas, whether or body cavities
of pallor pain is  This can help
b) be able to engage increasing, identify changes
in appropriate diffuse, or that can
behaviors to localized indicative of
prevent bleeding.  Assess skin blood loss
color or affecting
moisture circulation or
organ function
Tx:
 Provide  Ice compress
comfort decreases
measures such edema and
as application minimizes
of ice pack into hematoma and
the perineum, pain sensation
use of sitz bath while heat
or heat lamp promotes
to episiotomy vasodilation
extension. which facilitates
 Administer resorption of
pain hematoma.
medication  Decreases pain
(analgesic, and anxiety;
narcotic or Helps promote
sedative) as relaxation.
prescribed.

Edx:
 Encourage the  To assist the
use of client in
relaxation exploring
techniques methods for the
(e.g., deep control of pain.
breathing
exercise) and
diversional
activities (e.g.,
watching TV).  If bleeding
 Instruct at-risk occurs, patient
client and will have the
family knowledge of
regarding signs medical
specific signs attention in
of bleeding order to prevent
(postpartum blood loss
bleeding that complications
is bright red or
dark red with
large clots)
that require
attention of a
health care
provider
 FDAR

Date/Time Focus Data, Action, and Response

9/16/21 Risk for bleeding r/t pregnancy or postpartum D: Lacerations brought about by forceful
complications uncoordinated pushing.

A:
Dx:
 Performed pain assessment by
identifying the type, location,
characteristic, severity, and duration
of the pain. Use a pain scale of 0-10
 Monitor perineum in a postpartum
client, including wounds, dressings or
tube in a client with trauma
 Note client’s report of pain in specific
areas, whether pain is increasing,
diffuse, or localized
 Assess skin color or moisture
Tx:
 Provide comfort measures such as
application of ice pack into the
perineum, use of sitz bath or heat
lamp to episiotomy extension.
 Administer pain medication
(analgesic, narcotic or sedative) as
prescribed.
Edx:
 Encourage the use of relaxation
techniques (e.g., deep breathing
exercise) and diversional activities
(e.g., watching TV).
 Instruct at-risk client and family
regarding specific signs of bleeding
 (postpartum bleeding that is bright
red or dark red with large clots) that
require attention of a health care
provider

R: Patient verbalized relief from pain and

discomfort.

FDAR

Date/Time Focus Data, Action, and Response

9/16/21 Preeclampsia and Labor Pain D:
 Patient was received on wheelchair
with a blood pressure of 150/100
mmhg.
 Patient complaint of labor pain every
3 minutes interval and 60 seconds
duration of contraction
A:
Dx:
 Monitor and record uterine activity
with each contraction.
 Monitor maternal BP and pulse, and
FHR. Observe unusual adverse
reactions to medication, such as
antigen-antibody reactions,
respiratory paralysis, or spinal
blockage. Note adverse reactions such
as nausea/vomiting, urine retention,
delayed respiratory depression, and
pruritus of face, eyes, or mouth.
Tx:
 Transferred to Delivery room table
 and Prepared sterile delivery
instruments and supplies
 Administer magnesium sulfate as
ordered and Urinary indwelling
catheter was inserted for Renal
output monitoring
 Cleaned the perinium and prepare
lidocaine injection and cromic suture
to reparir the laceration
Edx:
 Encourage client/couple to manage
efforts to bear down with
spontaneous, rather than sustained,
pushing during contractions. Stress
importance of using abdominal
muscles and relaxing pelvic floor.
 Encourage client to relax all muscles
and rest between contractions.

R:
 Delivered a healthy baby boy weighing
2.7 kgs. Watchout for post partum
hemorrhage and report to attending
physician any unusaul event.