COR JESU COLLEGE, INC.

,
College of Health Sciences
Sto. Rosario, Tres De Mayo, Digos City

NURSING CARE PLAN 1

Name of Patient: Mrs. B Age: 28

Sex: Female Civil Status: Married
Religion: Roman Catholic Area: Rosa Sanz Street, Bansalan, Davao, del Sur
Date of Admission: 04-26-2022 Attending Doctor: Dr. Mona Liza Mantilla, MD
Impression: 37 2/7 weeks AOG by LMP. Cephalic NSVD, to a live baby girl G4P1(1011)

Submitted by: Harold Kim S. Diasana BSN2-B from Group 1

Problems Nursing Scientific Goals/ Nursing Rationale Evaluation

Diagnosis Basis Objectives Interventions
Criteria
April 25, 2022 Deficient Postpartum After 3 days 1. Assess 1. The amount of blood loss and the presence GOAL IS MET!
2:00 PM fluid hemorrhage of nursing and record of blood clots will help determine the
volume (PPH) is intervention, the necessary interventions. The characteristics 1. Vital signs are within
Subjective related to defined as a the client will: characteris and quantity of blood passed can suggest normal range
Cues: excessive cumulative 1. Maintain tics, excessive bleeding. For example, bright red  T – 36.5 °C
 “Murag blood loss blood loss a blood amount, blood is arterial and can indicate lacerations  CR – 80bpm
huyang ang after birth greater than or pressure and site of of the genital tract; meanwhile, dark red blood  RR – 16cpm
akoang as equal to 1,000 of at least the is likely of venous origin and may indicate  BP – 12080mmHg
tibuok evidenced mL of blood 100/60 bleeding, superficial lacerations or varices of the birth 2. Intake and Output are
lawas” as by loss mm Hg. including canal. Spurts of blood with clots can indicate within normal range.
verbalized decreased accompanied 2. The client the stage partial placental separation, excessive  Intake: 1000ml
by the in red by signs or will of labor. traction on the cord, and failure of the blood  Output: 1000ml
patient blood cell symptoms of maintain to clot or remain clotted may indicate
 count hypovolemia a pulse coagulopathy, such as disseminated 3. Cognitive Status: Awake
Objective Cues: (hematocri within 24 hours rate intravascular coagulation. Excessive and active.
 Pallor t) after the birth between 2. Count and 2. Be certain to differentiate between saturated 4. Less than 1 saturated
 1 day process, 70-90 weigh and used when counting perineal pads. perineal pad per hour.
vaginal regardless of beats per perineal Weighing perineal pads before and after use 5. Client is well hydrated
bleeding route of minute. pads and, and then subtracting the difference is an as evidenced by good
 Unable to delivery. 3. The client if possible, accurate technique to measure vaginal capillary refill, adequate
rise from Nevertheless, a will have preserve discharge: 1 g of weight is comparable to 1 urine output, and skin
bed blood loss a blood clots mL of blood volume. Saturation of a peripad turgor.
 Lethargic greater than balanced to be within 15 minutes to 1 hour after delivery  Capilarry refill: 2
500 mL in a 24-hour evaluated must be promptly reported. Always be sure to seconds
 Poor skin
vaginal delivery intake by the turn the client on her side when inspecting for
turgor
should be and primary blood loss to be certain a large amount of
Vital Signs: considered output. care blood is not pooling undetected beneath her.
 T – 36.5 °C abnormal 4. The client provider.
 PR – 96bpm (American will have 3. Assess the 3. Observing the lochia provides for an estimate
College of a lochia for of the actual blood loss. Lochia rubra should
 RR – 28cpm
Obstetricians cognitive color, be dark red. During the first few hours, the
 BP –
and status quantity, amount of lochia should be no more than one
100/65mmH and clots.
g Gynecologists within the saturated perineal pad per hour. Small clots
[ACOG], 2017). expected may appear in the drainage, but large clots
Lab Results: range. are not normal.
4. Assess the
 ABGs: 5. The client 4. The degree of uterine contractility will
location of
pH: 6 will have measure the status of the blood loss. Uterine
the uterus
PaO2 a lochia atony allows the blood vessels at the
and the
70mmHg flow of placenta site to bleed freely and usually
degree of
PaCO2 less than massively because the muscle fibers that
contractility
29mmHg one compress the bleeding vessels are flaccid.
of the
 Hematocrit/ saturated Large venous areas are exposed after the
uterus.
Hemoglobin: perineal placenta separates from the uterine wall and
pad per bleeding is controlled by the contraction of
 29% hour. smooth muscles in the uterus. The best
 Prolactin 6. The client safeguard against uterine atony is to palpate
Test: 60 will the client’s fundus at frequent intervals to
µg/L demonstr ensure her uterus remains contracted. The
ate 5. Assess for fundus should be firm to compress the
improvem additional bleeding vessels at the placenta site.
ent in the risk factors 5. Identifying the presence of risk factors for
fluid for hemorrhages such as retained placental
balance postpartum fragments, uterine or cervical lacerations,
as hemorrhag abnormal attachments to the placental site,
evidence e. uterine atony, or inadequate blood
d by a coagulation will help determine the
good 6. Monitor management of the situation, thus preventing
capillary vital signs, further complications.
refill, including 6. Routine postpartum care involves assessing
adequate systolic the vital signs every 15 minutes until stable. If
urine and the client has tachycardia and hypotension,
output, diastolic suspect for a considerable amount of blood
and skin blood loss, usually representing 25% of the client’s
turgor. pressure, total blood volume, or approximately 1,500
pulse, and mL or more (Brown, 2017). Tachycardia is
heart rate. usually the first sign of inadequate blood
Check for volume (hypovolemia). The first blood
the pressure change is a narrow pulse pressure
capillary (a falling systolic pressure and a rising
refill and diastolic pressure). The blood pressure may
observe continue to fall and eventually cannot be
nail beds detected.
and
mucous
membrane
 s.
7. Assess for
the
presence 7. A hematoma is a collection of blood within
of a vulvar the tissues and may result from birth trauma,
and and they appear as a bulging or purplish
vaginal mass. The client may also develop signs of
hematoma. concealed blood loss if the hematoma is
large. Larger ones may require incision and
drainage of the clots. The client should report
signs of concealed blood loss accompanied
by maternal complaints of severe pain,
8. Measure a perineal or vaginal pressure, or inability to
24-hour void. Small hematomas usually resolve
intake and without treatment or with cold application.
output. 8. Assessment of the client’s intake and output
Observe will help determine fluid loss. Monitoring urine
for signs of output is a good gauge of blood loss because
voiding the kidneys need sufficient arterial blood flow
difficulty. and pressure to function. If they are not
producing urine, it suggests the kidneys are
not obtaining adequate blood. Voiding
9. Investigate
difficulty may happen with hematomas in the
reports of
upper portion of the vagina, causing pressure
persistent
in the urethra.
perineal
9. Hematomas often result from continued
pain or
bleeding from lacerations of the birth canal. If
feeling of
the client reports severe pain in the perineal
vaginal
area or a feeling of pressure between her
fullness.
legs, inspect the perineal area to see if a
Apply
 counterpre hematoma could be causing this. Depending
ssure on on the amount of blood in the tissues, the
labial or client may describe the pressure in the vulva,
perineal pelvis, or rectum. Urination may be difficult or
lacerations absent due to the pressure.
10. Measur
e
hemodyna
mic 10. Measurement of the hemodynamic
parameters parameters will provide a direct measurement
, including of circulating volume, replacement needs,
central and response to therapy in case of a life-
venous threatening situation. Invasive monitoring with
pressure an arterial line, central line, and non-invasive
(CVP) or or minimally invasive cardiac output
pulmonary monitoring may be considered according to
artery PPH severity and availability (Muñoz et al.,
wedge 2019).
pressure
(PAWP) if
available.

COR JESU COLLEGE, INC.,

 College of Health Sciences
Sto. Rosario, Tres De Mayo, Digos City

NURSING CARE PLAN 2

Name of Patient: Mrs. B Age: 28

Sex: Female Civil Status: Married
Religion: Roman Catholic Area: Rosa Sanz Street, Bansalan, Davao, del Sur
Date of Admission: 04-26-2022 Attending Doctor: Dr. Mona Liza Mantilla, MD
Impression: 37 2/7 weeks AOG by LMP. Cephalic NSVD, to a live baby girl G4P1(1011)

Submitted by: Harold Kim S. Diasana BSN2-B from Group 1

Problems Nursing Scientific Goals/ Nursing Rationale Evaluation

Diagnosis Basis Objectives Interventions
Criteria
April 25, 2022 Ineffective Postpartum After 3 days 1. Monitor 1. If the uterus suddenly relaxes, there will be GOAL IS MET!
3:00 PM peripheral hemorrhage of nursing the an abrupt gush of blood vaginally from the
tissue (PPH) is intervention, client’s placental site. This can occur immediately 6. Vital signs are within
Subjective perfusion defined as a the client will: vital signs after birth but is more likely to occur normal range
Cues: related to cumulative 1. Demonstr closely. gradually, over the first postpartum hour, as  T – 36.5 °C
 “Kanunay hypovolem blood loss ate vital the uterus slowly loses its tone. If the blood  CR – 80bpm
kung ia as greater than or signs loss is extremely copious, the client will  RR – 16cpm
nabugata evidenced equal to 1,000 within the quickly begin to exhibit symptoms of  BP – 12080mmHg
n ug by mL of blood expected hypovolemic shock such as falling blood 7. The client exhibits
gikapoy” decreased loss range. pressure’ a rapid, weak, or thready pulse; values of ABGs and
as capillary accompanied 2. The client increased and shallow respirations; pale, hematocrit/hemoglobin
verbalized refill by signs or will clammy skin; and increasing anxiety. With within an acceptable
by the symptoms of exhibit slow bleeding, there is little change in pulse range.
patient. hypovolemia laborator and blood pressure at first, but then
 within 24 hours y values suddenly, the system cannot compensate  ABGs –
Objective Cues: after the birth of arterial anymore, and the pulse rate rises but pH: 7.40
 Pale process, blood becomes weak, and blood pressure drops PaO2: 85mmHg
2. Monitor
 Pale regardless of gases abruptly. PaCO2: 40mmHg
the
palpebral route of (ABGs) 2. Pulse oximetry is useful in evaluating tissue  Hematocrit/
client’s
conjunctiv delivery. and perfusion and oxygen saturation. Monitoring Hemoglobin – 39%
oxygen
a Nevertheless, a hematocri blood pressure and oxygen saturation 8. The client demonstrates
saturation
 Pale lips blood loss t/hemoglo combined with maternal characteristics, normal hormonal
levels.
 Capillary greater than bin within symptoms, and laboratory measurements function by adequate
refill: 4 500 mL in a an creates a trigger system that can find 75% of supply of lactation.
seconds vaginal delivery acceptabl pre-eclamptic and hemorrhagic clients who  Prolactin Test: 100
should be e level. 3. Observe developed serious complications (Hannola et µg/L
Vital Signs: considered 3. The client the color al., 2021).
 T – 36.5 °C abnormal will of the nail 3. The body compensates for volume loss by
 PR – 96bpm (American demonstr beds, baroreceptor activation resulting in
 RR – 28cpm College of ate gums, sympathetic nervous system activation and
 BP – Obstetricians normal tongue, peripheral vasoconstriction. With the
100/65mmH and hormonal and vasoconstriction compensation and shunting
g Gynecologists functionin buccal to vital organs, circulation in the peripheral
[ACOG], 2017). g by mucosa. blood vessels is diminished, resulting in
Lab Results: adequate Note the cyanosis and cold skin temperatures
 ABGs: milk temperatu (Hooper & Armstrong, 2021).
pH: 6 supply for re of the
PaO2 lactation skin.
70mmHg (as 4. Evaluate
PaCO2 appropria the 4. Changes in the mentation are an early sign
29mmHg te) and neurologic of hypoxia. Blood flow to nonessential
 Hematocri resumptio status and organs is restricted to essential organs like
t/ n of observe the brain. However, if blood loss continues,
Hemoglob normal for any flow to the brain decreases, resulting in
menstrua behavioral
 in: 29% tion. changes. mental changes such as anxiety, confusion,
 Prolactin 5. Monitor and lethargy.
Test: 60 CBC and
µg/L coagulatio
n values 5. Hemoglobin is invariably overestimated
before during resuscitation of ongoing hemorrhage.
and after Therefore, it should be maintained at greater
blood than 8 g/dL. Regular CBC and coagulation
loss. tests may guide blood component therapy.
6. Monitor However, hemoglobin/hematocrit are of
arterial little/no value in the initial resuscitation of
blood acute hemorrhage (Sharma, 2019).
gases 6. ABG and pH levels determine the degree of
(ABGs) tissue hypoxia or acidosis, indicating the
and pH build-up of lactic acid resulting in anaerobic
levels. metabolism. Blood is diverted away from
noncritical organs and tissues to preserve
blood supply to vital organs. Prolonging
heart and brain function also leads to other
tissues being further deprived of oxygen,
causing more lactic acid production and
worsening acidosis (Hooper & Armstrong,
2021).