A.

HEALTH CARE PLAN

Problem #1: Severe Bleeding Due to Retained Fragments
Assessment Diagnosis Planning Implementation Evaluation
Subjective Independent Rationale
“Marami parin yung Risk for ineffective tissue After 2 hours of  Establish rapport.  For nurse/midwife-client After 2 hours of
nararamdaman kong perfusion related to intervention, the client relationship. intervention, the goal
nalabas sakin na dugo.” severe bleeding due to will demonstrate  Assess  The amount of blood during was not met because
as stated by the client. retained fragments. adequate perfusion characteristics and first few hours after delivery the patient was
and stable vital signs. amount of blood. should be no more than one referred to the other
Objective saturated perineal pad per facility to receive
 Vital sign taken as hour. D&C procedure.
 Monitor client’s vital
follows:  Rise in pulse rate may indicate
signs.
CR: 65 bpm the inadequate blood volume
RR: 22 cpm and decrease in blood pressure
T: 36.7 °C may also occur.
 Capillary refill: > 3  Gently massage the  To help expel blood clots and
seconds fundus of the uterus to check the tone of the uterus
 Pale lips of the client. to prevent excessive bleeding.
 Pale conjunctiva  Count and weigh the  Estimated count of blood loss
client’s perineal in given lengths of time can be
pads. formed.

 Provide comfort to  For the client to be relaxed and

the client such as it may enhance the client’s
back rubs, deep coping abilities by redirecting
breathing. As well as their attention.
instructing the client
in relaxation
exercises.

Dependent
Administer medications To promote contraction and to
as ordered. prevent further bleeding.
Table 14.1 Severe Bleeding Due to Retained Fragments
 Problem #2: Low Hemoglobin
Assessment Diagnosis Planning
Subjective
“.” As verbalized by the Risk for bleeding related  The client will show
client. to postpartum decreased risk for
Objective complication. bleeding as evidenced
 Laboratory result: by adequate levels of
platelets.
 The client will be free
of signs of active
bleeding or excessive
blood loss, as
evidenced by stable
vital signs and mucous
membranes is free of
pallor.
Implementation
Independent
 Keep fluids within
reach of the client.
 Establish rapport.
 Monitor client’s vital
signs.
 Instruct and teach the
patient about the
bleeding precautions.
Evaluation
 to encourage fluid intake After the interventions, the
client’s goal was partially met.
 For nurse/midwife-client
relationship.
 Rise in pulse rate may
indicate the inadequate
blood volume and
decrease in blood
pressure may also occur.
 If the client’s platelet
counts continues to drop,
bleeding precautions
should be advised to
avoid spontaneous
bleeding.

 For the client to be

 Provide comfort to the relaxed and it may
client such as back enhance the client’s
rubs, deep breathing. coping abilities by
As well as instructing redirecting their attention.
the client in relaxation
exercises.  It s important to instruct
client to eat foods with
 Advise client to eat essential nutrients to
foods that are rich in promote RBC formation.
iron, folic acid, and
vitamin B12.
 Verbalization of their
 Encourage the client to feelings will help them to
 verbalize feelings cope with their condition.
about their limitations.

Dependent
Administer medication as
per doctor’s order

To promote contraction and to

prevent further bleeding.
Table 14.2 Low Hemoglobin