Name of Student: Phoebe Lynn S.

Posecion Section and Group number: BSN2C Group 4

Assessment Nursing (Rationale)

NURSING Desired
CARE PLAN Nursing Justification Evaluation
Cues Diagnosis Pathophysiologic / Schematic Diagram Outcome Intervention
Thirty minutes
after her first Deficient fluid Predisposing Precipitating After 8 hours of After a series of
complaint: volume related to factors factors Nursing Care, the nursing care the
excessive bleeding patient is expected to: patient is able to:
after birth as  Age  Weight
Subjective:  Gender  Multiple
evidenced by boggy  Patient will  Assess and record  The amount of  Have a stable
Elsa verbalized “I  Nationality pregnancy
uterus, heavy maintain a the type, amount, blood loss and the blood
don’t feel good. I  overdistended
vaginal bleeding blood pressure and site of the presence of blood pressure as
feel dizzy and I have uterus
clammy skin, Pale of at least bleeding; Count clots will help to evidenced by
abdominal pain”
lips, Facial Grimace, 100/60 mm and weigh perineal determine the a continuous
“I rate my pain Hg. pads and if appropriate monitoring of
T=31.1, P= 120
8/10” Bpm, RR= 28cpm, Predisposing/ Precipitating Factors possible, save replacement need vital signs
BP 90/60 mmHg, ↓ blood clots to be of the patient. every 4 hours
Objective: HCT- 0.35, RBC – Normal Delivery of the baby evaluated by the that resulted
Clammy skin, Pale 4.4, HGB -110, WBC ↓ physician. to an
lips and Facial – 28, NA (Sodium) – Gravid uterus is not able to contract strongly increase.
Grimace 140.7, K enough From 90/60
(Potassium) – 4.87 ↓ mmHg to
and Chloride -107.9 The placenta will separate from the uterine 100/20
Boggy uterus and
interface, exposing maternal blood vessels that mmHg and
Vaginal Bleeding interface with the placental surface. 100/40
↓ mmHg.
T= 31.1 Celsius The uterus initiates a process of contraction and
Definition:
P= 120 Bpm retraction, shortening its fiber and kinking the Goal Partially Met
Decreased
RR= 28 cpm supplying blood vessels.
intravascular,
BP= 90/60 mmHg ↓  Patient will  The degree of the  Maintain a
interstitial, and/or Due to uterine atony, blood vessels bleed freely maintain a  Assess the location contractility of the pulse rate
intracellular fluid. and hemorrhage occurs
Blood loss of pulse rate of the uterus and uterus will between 70-
This refers to ↓
450ml after birth between 70- Massage boggy measure the 90 beats per
dehydration, Deficient fluid volume 90 beats per uterus using one status of the minute as
water loss alone minute. hand and place the blood loss. Placing evidenced by
Lab results:
without change in second hand above one hand just a continuous
sodium. the symphysis above the monitoring of
pubis. symphysis pubis vital signs
CBC
HCT- 0.35 Reference: Maame Yaa A B Yiadom, MD, MPH will prevent every 4 hours
RBC -4.4 (January 02, 2018) Pathophysiology of possible uterine that resulted
HGB- 110 Source/Reference postpartum hemorrhage (PPH) Retrieved from: inversion during a to a decrease.
WBC- 28 NANDA https://www.medscape.com/answers/796785- massage. From 120
bpm to 85
122138/what-is-the-pathophysiology-of-
bpm and 80
ELECTROLYTES postpartum-hemorrhage-pph
bpm.
NA (SODIUM) -
140.7 Goal Met
K (POTASSIUM) -  Patient will
4.87 have a lochia  Determine
CHLORIDE- 107. 9 flow of less  Save all perineal her own fluid
than one pads used during  to determine the loss with the
saturated bleeding and weigh amount of blood help of the
Strength: perineal pad them loss. student nurse
 Supportive per hour. as a verbal
husband evidence of
“When I saw
 Positive
my perineal
Outlook in
pad, I can say
life that the fluid
loss is lesser
than the one
before. Thank
Weakness: you so much
 Poor for your
Financial guidance
status nurse
phoebe”

Goal Met

 Patient will
have a  Have a lochia
balanced 24- flow of less
hour intake  Assess lochia than one
and output. frequently  To determine if saturated
the amount perineal pad
discharged is still per hour as
within the normal evidenced by
 limits. a continuous
assessment of
the lochia
every hour

Goal Met

 Patient will  Demonstrate

demonstrate improvement
improvement  Monitor vital signs in the fluid
in the fluid including systolic balance as
balance. and diastolic blood  Increased heart evidenced by
pressure, pulse and rate, low blood a good
heart rate. Check pressure, capillary refill,
for the capillary cyanosis, delayed adequate
refill and observe capillary refill urine output,
nail beds and indicates and skin
mucous hypovolemia and turgor.
membranes. impending shock.
Decrease fluid Goal Partially Met
volume of 30-50%
will reflect
changes in the
 Note for the blood pressure.
presence of vulvar
hematoma and  Small hematoma
apply an ice pack if can be managed
indicated. by an ice pack and
rest.
 Measure a 24-hour
intake and output.
Observe for signs  This will help in
of voiding difficulty. determining the
fluid loss. A urine
output of 30-50
ml/hr or more
indicates an
adequate
circulating
 volume. Voiding
difficulty may
happen with
hematomas in the
 Observe for reports upper portion of
of persistent the vagina causing
perineal pain or pressure in the
feeling of vaginal urethra.
fullness. Apply
counterpressure on  Hematomas often
labial or perineal result from
lacerations. continued
bleeding from
laceration of the
 Maintain a bed rest birth canal.
with an elevation
of the legs by 20-
30° and trunk
horizontal.
 The position
increases venous
return, making
sure a greater
availability of
blood to the brain
and other vital
organs. Bleeding
 Start 1 or 2 IV may be decreased
infusion(s) of with the bed rest.
isotonic or
electrolyte fluids
with an 18-gauge
catheter or via a  This is important
central venous line. for rapid or
Administer fresh multiple infusions
whole blood or of fluids or blood
other blood products to
products (e.g., increase
platelet circulating volume
 concentrate, and enhance
plasma, clotting. Note:
cryoprecipitate) as Each unit of
indicated whole blood
increases the
hematocrit level
 Administer by three
cefuroxime, percentage
hemostan and points.
ferrous sulfate as
per doctor’s
request.
 To prevent
bacteria and
viruses from
 Monitor the laceration, to
laboratory values lessen lochia flow
of hemoglobin and and increase the
hematocrit input of iron.

 Hgb and Hct

 Prepare the patient determine the
for blood amount of blood
transfusion by loss. Each milliliter
requesting cross of blood carries
matching of the 0.5 mg
blood request type of hemoglobin.
B 2-3 units of
packed RBC
 To detect the
presence of
antibodies in the
recipient against
the red blood cells
of the donor and
to detect the
blood
compatibility.
Name of CI: _______________________________ ______

Area of Exposure: OB Ward