ASSESSMENT DIAGNOSIS GOALS INTERVENTIONS RATIONALE EVALUATION

Deficient fluid Short term: Independent: Independent Goals met

volume related to
Objective Data: excessive blood After 4 to 8 hours of ● Monitor vital ● To have
loss after birth performing specific signs and LOC, baseline data
PR: 120 nursing interventions especially PR as bleeding
BP: 70/40 the client will: and BP causes
60/40 hypotension
● Display and
normal vital tachycardia
signs within
normal range ● Assess skin ● Poor skin
(PR and BP) turgor and turgor and
● Have a capillary refill poor capillary
cognitive refill could
status within indicate fluid
the expected volume
range deficiency
● Have a good
skin turgor ● Monitor signs ● Excessive
and capillary of shock bleeding
refill oould lead to
● Will have a shock
lochia flow of
less than one ● Monitor signs ● Retained
saturated of placental
perineal pad disseminated fragments can
per hour intravascular remain in the
coagulation uterus after
spontaneous
separation of
Long term: the placenta
causing
After 24-72 hours of excessive
performing specific bleeding
nursing interventions
the client will: ● Monitor peri ● To further
pad and lochia assess for the
● Maintain of the patient severity of
normal vital bleeding
signs within
normal range ● Maintain bed ● Rest and
(PR and BP) rest with an elevation of
● Have a elevation of the legs helps
balanced legs by 20-30 venous return
24-hour degrees and slows
intake and bleeding
output
● Have normal ● Assess input ● To monitor
results of and output fluid volume
laboratory status of the
exams patient
● Demonstrate
improvement ● Increase fluid ● Can help in
in the fluid intake fluid volume
balance balance

● Educate the ● Signs and

client or symptoms of
significant a possible
others on cause of
identifying the bleeding
signs and should be
symptoms that reported.
 need to be
reported
urgently

Dependent: Dependent:

● Obtain blood ● initial

tests to assess measurement
hemoglobin is useful to
and hematocrit determine a
levels baseline
hemoglobin
level as
anemia is very
frequent in
parturients
and also to
assess
effectiveness
of the
therapy
● Obtain blood
tests to assess ● These lab
platelet count exams could
activated help further
partial assess the
thromboplastin bleeding
time (APTT),
fibrinogen, and
fibrin
degradation
 products
(FDP),

● To accurately
● Review the perform blood
client’s blood trasfusion
typing and
crossmatching
results

● Administer IV ● Fluid
fluids as replacement
needed may be
necessary
and,
depending on
the amount of
blood lost and
hematocrit
level

● Administer ● To
fresh whole compensate
blood or other in excessive
blood products blood loss
as needed

● Administer ● Certain
medication as medications
ordered
 like antibiotics
is needed to
prevent
infection

● Insert an ● To accurately
indwelling measure the
Foley catheter renal status
as needed and perfusion
concerning
fluid volume

Collaborative Collaborative

● Prepare the ● Some patients

client for may needed
surgical special
intervention if interventions
needed like surgical
procedures to
stop the
bleeding
Rojas, Abramme

Assessment Nursing Diagnosis Goals Nursing Rationale Evaluation

Interventions

Objective Cues ● Deficient Fluid ● Maintain fluid Independent ● Although fluid ● Maintained fluid
● BP: 60/40 Volume related volume at a ● Weigh the client intake and volume at
● RR: 37 cpm to postpartum functional level daily and weight gain functional level
● PR: 91 Hemorrhage as evidenced by compare with greater than evidenced by
● + Stridor evidenced by individually 24-hour intake output may not adequate
hypotension, adequate and output. accurately urinary output
tachycardia, urinary output reflect with normal
and tachypnea with normal intravascular specific gravity,
specific gravity, volume, these stable vital
stable vital measurements signs, moist
signs, moist provide mucous
mucous valuable data membranes,
membranes, for comparison. good skin
good skin ● Monitor vital ● Tachycardia turgor, prompt
turgor, prompt signs and CVP. and a varying capillary refill
capillary refill, Observe for degree of and resolved
and resolution temperature hypotension are edema
of edema. elevation and present,
● The patient will orthostatic depending on ● Demonstrated
maintain blood hypotension. the degree of behaviors to
pressure of at fluid deficit. monitor and
least 100/60 CVP correct deficit,
mm Hg measurements as indicated
● Demonstrate help determine ● The client
behaviors to the degree of verbalized
monitor and fluid deficit and understanding
 correct deficit, response to of causative
as indicated. replacement factors and the
● The client will therapy. Fever purpose of
verbalize increases therapeutic
understanding metabolism and interventions.
of causative exacerbates
factors and the fluid loss.
purpose of ● Monitor for a ● Too rapid a
therapeutic sudden or correction of
interventions. marked fluid deficit may
elevation of compromise the
blood pressure, cardiopulmonar
dyspnea, y system,
basilar crackles, especially if
frothy sputum, colloids are
moist cough, used in general
and fluid
restlessness. replacement.

Dependent ● Intravenous
● Administering fluids such as
intravenous lactated
fluids as Ringer's
indicated solution or
normal saline
may be
administered to
restore blood
volume.
● Enteral
● Provide tube replacement
feedings, can provide
including free proteins and
water, as other needed
appropriate. elements in
 addition to
meeting general
fluid
replacements
when
swallowing is
not intact.
● If blood loss is
● Administering severe, a blood
blood transfusion may
transfusions as be necessary to
indicated restore blood
volume.

● This enhances
Collaborative cooperation
● Engage the with the
client, family regiment and
and all achievement of
caregivers in a goals
fluid
management
plan ● Monitoring the
patient for
● Monitoring for potential
potential complications
complications such as
infection,
thrombosis, and
renal failure,
and report any
abnormalities to
the healthcare
provider.
● Educate the
patient and their
● Education and family on signs
discharge and symptoms
planning to monitor for
after discharge
and collaborate
with the
healthcare team
to develop an
appropriate
discharge plan.
 Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Impaired gas Short term: Independent:

exchange related to ● Monitor ● Early After 15 minutes of
“nahihirapan hypovolemia as After 15 minutes of respiratory recognition and specific nursing
ako huminga” evidenced by specific nursing rate and treatment of intervention, the
as verbalized tachypnea and intervention, the patient depth. Note abnormal patient will:
by the patient. tachycardia. will: respiratory ventilation may ● Display a 12-20
● Display a 12-20 effort prevent cpm RR and
Objective: cpm RR and (presence of complications. heart rate
● RR: 37 heart rate dyspnea, use (60-100 bpm)
cpm (60-100 bpm) of accessory within the
● HR: 120 within the normal muscles, and normal range.
bpm range. nasal flaring) ● Be ease of
● Occasio ● Be ease of stridor.
nal stridor. ● Monitor vital ● Aids in early
stridor signs every 15 detection of
minutes. changes in Long term:
clinical After 24 hours of
● Maintain condition and specific nursing
Long term: bedrest in a assess intervention, the
After 24 hours of semi-Fowler’s response to patient will:
specific nursing position with treatment.
intervention, the patient the head of ● Maintain a
will: the bed respiratory rate
elevated 20 to and heart rate
● Maintain a 30 degrees. ● Reduces within the
respiratory rate oxygen normal range.
and heart rate ● Auscultate consumption ● Demonstrate
within the normal lungs for air and demands absence and
range. movement and and promotes nonrecurrence
● Demonstrate abnormal maximal lung of stridor.
absence and breath sounds. inflation. ● Maintain an
nonrecurrence of adequate gas
stridor. ● The presence exchange.
● Maintain an of stridor and
 adequate gas ● Monitor heart other
exchange. rate and adventitious
● Verbalize rhythm lung sounds
understanding of could indicate
causative factors distress.
and appropriate
intervention ● Monitoring the
heart rate and
rhythm can
help to identify
changes in the
patient's
cardiac
function that
● Observe for may indicate
cyanosis and the severity of
monitor pulse hypovolemia.
oximetry.

● For early
Dependent: recognition of
systemic
● Administer hypoxemia
oxygen
therapy as
needed.

● Helps to
improve
● Administer oxygenation
medications and reduce the
as prescribed work of
to address breathing.
underlying
conditions or
 symptoms ● Administering
(such as pain, medications
anxiety, or such as
hypotension). antibiotics can
help to improve
lung
● Administer compliance and
fluids, IV or by reduce the
mouth (PO), need for
as indicated. mechanical
ventilation.

● To reduce
hyperviscosity
of blood, which
can potentiate
thrombus
Collaborative: formation, or to
support
circulating
● Prepare for volume and
additional tissue
referrals and perfusion.
interventions,
such as to a
pulmonary
● A
specialist, to a
multidisciplinar
pulmonary
y approach
rehabilitation
including
pro- gram, or education and
for surgical exercise
intervention, training may be
as helpful in
appropriate. improving client
function and
 quality of life
● Assist with
noninvasive ● Development of
(nasal or or impending
oronasal) respiratory
intermittent failure requires
positive-press prompt
ure ventilation life-saving
(NIPPV) or measures.
intubation and
institution and
maintenance
of mechanical
ventilation;
transfer to a
critical care
unit depending
on client
directives.

● Assist with
respiratory
treatments

● improve gas
exchange in
patients with
impaired gas
exchange by
addressing
underlying
causes,
improving
oxygenation
and ventilation,
and preventing
complications.
○