University of Saint Louis

Tuguegarao City, Cagayan 3500

SCHOOL OF HEALTH AND ALLIED SCIENCES
COLLEGE OF NURSING
2ND SEMESTER, AY 2021-2022
BACHELOR OF SCIENCE IN NURSING – LEVEL IV
Name of Patient: Babeth
Diagnosis or Clinical Impression: Disseminated Intravascular Coagulopathy

Assessment/Cues Nursing Background Goals and Objectives Nursing Evaluation

Diagnosis Knowledge Interventions and
Rationale
Subjective: “ Ang Deficient fluid Disseminated After 20 minutes of Independent nursing After 20 minutes
sakit ng tiyan ko at
volume intravascular medical and nursing intervention: if independent and
parang naninigas (Isotonic) coagulopathy is a management/ dependent nursing
related to serious condition in intervention the patient interventions the
pa” as verbalized
prolonged which there is an should be able to 1. Monitor vital signs baby was
by the patient
uterine impaired blood maintain fluid (isotonic) every 5 minutes delivered and the
bleeding as clotting thus volume at normal levels patient’s bleeding
evidenced by causing as evidenced by  To identify any has stopped with
 Pain scale = Uterine uncontrollable stoppage of bleeding changes that vital signs and
6/10 tenderness (+) bleeding. One cause and normal VS and may lead to a laboratory values
of DIC is placental laboratory values more serious returning to
abruption where the condition normal ranges
Objective: placenta completely especially on
separates from the older adults
 Presence of
blood in the uterine wall thus 2. Encourage patient Goal Met
vagina (+) causing the baby to frequent fluid intake
 Uterine harm and also older adults should
Tenderness bleeding for the have more fluid intake
(+) mother. than the normal young
 Pale skin adult
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
COLLEGE OF NURSING
2ND SEMESTER, AY 2021-2022
BACHELOR OF SCIENCE IN NURSING – LEVEL IV
(+)  To replace loss
 Increased fluids and
Heart rate= prevent
115 bpm dehydration.
 Elevated
3. Observe for moist
Blood
cough, dyspnea and
pressure=
frothy sputum if
140/62
present report
mmhg
immediately to
 Decreased
physician
Hemoglobi
n level= 8.1  Rapid
g/dl correction of
 Decreased fluid deficit
platelet may
count= 93 x compromise
109/ l the
 D- dimer cardiopulmona
(+) ry system.
 Increased
INR= 2.2 4. Instruct the patient
to listen to music
 Music can
distract the
patient to
minimally
reduce the pain
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
COLLEGE OF NURSING
2ND SEMESTER, AY 2021-2022
BACHELOR OF SCIENCE IN NURSING – LEVEL IV
felt

Dependent nursing
intervention:

1. Administer
Syntocinon
immediately
 Induce labor to
deliver the
baby via
vagina
2. Administer IV
fluids as ordered
 To replace lost
body fluids and
prevent the
occurrence of
hypovolemic
shock
3. Administer
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
COLLEGE OF NURSING
2ND SEMESTER, AY 2021-2022
BACHELOR OF SCIENCE IN NURSING – LEVEL IV
anticoagulants
 To fix blood
clotting
impairments
and bleeding
4. Start Blood
transfusion
 To
appropriately
replace loss
blood volume
due to bleeding
and prevent the
occurrence of
hypovolemic
shock

5. Oxygen
administration as
ordered
 To increase the
amount of
oxygen carried
by available
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
COLLEGE OF NURSING
2ND SEMESTER, AY 2021-2022
BACHELOR OF SCIENCE IN NURSING – LEVEL IV
hemoglobin in
the blood