NURSING CARE PLAN

PROBLEM #1
Defining characteristics Nursing diagnosis Outcome Identification Nursing intervention Rationale Evaluation

Subjective: Acute pain related to Long term: After a week of Independent- The goal has been
“ may ginabatyagan ako physiological nursing intervention, there  Change wet clothing and  Promotes warmth, comfort, and met as the patient
nga sakit kag palanig ah response following will be significant progress bedding. cleanliness. verbalize of
saakon nga tyan.”as delivery. in the healing process as  Apply ice bags to perineum after  Constricts blood vessels, reduces management of
verbalized by the patient. evidence by: delivery. edema, and provides local comfort reduction of pain.
1.) Proliferative phase and anesthesia.
RATIONALE: Note: 2.) No inflammation noted.  Provide a heated blanket.  Post-delivery tremors/chills may be
Nursing caused by sudden release of pressure
Objective: diagnosis should be Short term: After 8 hours on pelvic nerves or may possibly be
Temperature: 36.1°C based on (NANDA- shift of nursing intervention, related to a fetus-to-mother
Pulse Rate: 90 bpm American Nursing the patient will verbalize the transfusion occurring with placental
Respiratory Rate: 18 cpm Diagnosis) management of reduction of separation. Warmth promotes muscle
Blood Pressure: 110/80 relaxation and enhances tissue
pain.
mmHg perfusion, reducing fatigue and
BP-120/70mmHg (after enhancing sense of well-being.
birth)  Assist with use of breathing  Breathing helps direct attention away
Sudden gush of blood techniques during surgical repair, from the discomfort, promotes
Lengthening of umbilical as appropriate. relaxation.
cord.

NURSING CARE PLAN

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
5000, Philippines

PROBLEM #2
Defining Nursing Outcome Nursing intervention Rationale Evaluation
characteristics diagnosis Identification

Subjective: Risk for fluid Long term: After a Independent- The goal has been met
“ may ginabatyagan volume deficit couple of months of as the client
ako nga sakit kag • Assess vital signs before and after • Hypertension is a frequent side effect of
related to nursing intervention, demonstrated adequate
palanig ah saakon administering oxytocin. oxytocin.
retained placental the patient will be to contraction of the
nga tyan.”as fragments. maintain normal uterus with blood loss
• Instruct the client to push with • Client attention is naturally on the newborn;
verbalized by the range of BP and heart withing normal limit.
patient. contractions; help direct her attention in addition, fatigue may affect individual
rate. toward bearing down. efforts, and she may need help in directing
RATIONALE: her efforts toward assisting with placental
Note: Nursing separation. Bearing down helps promote
Objective: diagnosis should Short term: After 8 separation and expulsion, reduces blood loss,
Temperature: 36.1°C be based on hours shift of nursing and enhances uterine contraction.
Pulse Rate: 90 bpm (NANDA- intervention, the • Monitor for signs and symptoms of
Respiratory Rate: 18 American excess fluid loss or shock (i.e., check BP, • Hemorrhage associated with fluid loss
patient will
cpm Nursing pulse, sensorium, skin color, and greater than 500 ml may be manifested by
demonstrate adequate
Blood Pressure: Diagnosis) temperature). increased pulse, decreased BP, cyanosis,
contraction of the
110/80 mmHg disorientation, irritability, and loss of
uterus with blood loss
BP-120/70mmHg consciousness.
within normal limit.
(after birth)
• Inspect maternal and fetal surfaces of • Helps detect abnormalities that may have an
Sudden gush of blood
placenta. Note size, cord insertion, impact on maternal or newborn status.
Lengthening of
umbilical cord. intactness, vascular changes associated
with aging, and calcification (which
possibly contributes to abruption).
• Obtain and record information related to
• Retained placental tissue can contribute to
inspection of uterus and placenta for
post partial infection and to immediate or
retained placental fragments.
delayed hemorrhage. If detected, the
fragments should be removed manually or
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
5000, Philippines
• Record time and mechanism of placental
separation; i.e., Duncan’s mechanism
(placenta separates from the inside to
outer margins) versus Schulze’s
mechanism (placenta separates from
outer margins inward).
• Massage uterus gently after placental
expulsion.
• Place infant at client’s breast if she plans
to breastfeed.
• Administer oxytocin (Pitocin) through
IM route, or dilute IV drip in electrolyte
solution, as indicated. IM
methylergonovine maleate (Methergine)
or prostaglandins may be given at the
same time.
with appropriate instruments.
• Separation should occur within 5 min after
birth. The Duncan’s mechanism of
separation carries increased risk of retained
fragments, necessitating close inspection of
the placenta. Failure to separate may require
manual removal. The more time it takes for
the placenta to separate, and the more time in
which the myometrium remains relaxed, the
greater the blood loss.
• Myometrium contracts in response to gentle
tactile stimulation, thereby reducing lochial
flow and expressing blood clots.
• Suckling stimulates release of oxytocin from
the posterior pituitary, promoting myometrial
contraction and reducing blood loss.
• Promotes vasoconstrictive effect within the
uterus to control post partal bleeding after
placental expulsion. IV bolus may result in
maternal hypertension. Water intoxication
may occur if electrolyte-free solution is used.