COLEGIO SAN AGUSTIN BACOLOD

COLLEGE OF HEALTH AND ALLIED PROFESSIONS

NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 – 24 71 Local 162
Email Address: csab.chap@gmail.com

NURSING CARE PLAN

Patient’s Name: Patient S Chief Complaint/s: Discomfort, Intermittent Abdominal Pain, and
Cramps

Room/Bed#: Labor Room Diagnosis/Impression: Postpartum Hemorrhage

Age: 18 Attending Physician: Dr. X

NURSING SPECIFIC NURSING

CUES RATIONALE RATIONALE EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTION

Subjective Pathophysiology Goals were met

 Hypovelemia
The patient is  After 8 hours 1. Assess the
The patient
  Fluid Volume  Postpartum due to PPH 

upset and of nursing patient’s vital

may lower was able to
Deficit related hemorrhage is
signs, particularly blood maintain a
anxious due interventions,
to blood defined as a blood
 volume loss loss of blood the patient blood pressure pressure pressure of
to discomfort levels and put 100/60
secondary to in the will level.
brought by the patient at mmHg.
postpartum postpartum demonstrate
risk for
the Patient will
hemorrhage period of more adequate hypotensive 
postpartum episodes that demonstrate
as evidenced than 500 mL. perfusion and
may lead to improvement
hemmorrhage
by urine The average, stable vital in the fluid
. Patient shock.
diaper with spontaneous signs. balance as
verbalized 2. Establish evidenced by
blood vaginal birth  This
a good
“nurse rapport and facilitates
discharges of will typically capillary refill,
gakabalaka accept behavior cooperation; adequate
650 cc. have a 500mL
ko kay daw urine output,
without judgment. provides an
blood loss. In and skin
indi ko Make verbal opportunity turgor.
cesarean
kainchindi contract about for the client
births the  The patient
ano ni ang expected to leave the
average blood was able to
gina batyag behaviors of client experience have a lochia
loss rises to
ko.” and nurse. flow of less
800 - 1000 with positive
than one
 Pain scale: feelings and saturated
mL. There is a
7/10 – severe enhanced perineal pad
greater risk of per hour.
pain self-esteem.
hemorrhage in
The patient  The patient
the first 24
verbalized in 3. Obtain  This is to was able to
hours after the balanced 24
pain “Indi ko informed consent provide the
birth, called hour intake and
na kaya nga before doing any patient with output.
primary
ah pwerte ini procedure. appropriate
 postpartum Explain information to
ka sakit?”
hemorrhage. the procedures make
 The patient
A secondary and the possible informed
describes her
hemorrhage risks associated choices.
financial
occurs after with labor and
situation as
the first 24 delivery.
"pwerte
hours of birth.
kapigado"
In the majority 4. Assess the  This is to
 The patient
of cases the amount of determine the
stated that amount of
cause of bleeding. Save all
her partner's blood loss.
hemorrhage is perineal pads
income is
uterine atony, used during
insufficient to
meaning that bleeding and
meet their
the uterus is weigh them.
needs.
not
contracting 5. Assess lochia  This is to
Objective determine if
enough to frequently.
control the the amount
 IV - 450 cc
bleeding at discharged is
 Soup - 150 cc
the placental still within the
 Water - 250
site. Other normal limits.
cc
reasons for a
 Juice - 150 cc
hemorrhage
 Water - 200
 would include 6. Assess the  The degree of
cc
retained location of the the
 Urine - 580 cc
placental uterus and degree contractility of
 Urine diaper
fragments of the contractility the uterus will
with blood
(possibly of the uterus/ measure the
discharges -
including a Massage boggy status of the
650 cc
placenta uterus using one blood loss.
 HBS Ag: Non-
accreta), hand and place Placing one
reactive
trauma of the second hand hand just
 Urinalysis:
some form, above the above the
Normal
like a cervical symphysis pubis. symphysis
 CBC: RBC =
laceration, pubis will
5.5 x 10¹²/L
uterine prevent
 WBC = 9.8 x
inversion, or possible
10⁹/L
even uterine uterine
 Hemoglobin =
rupture, and inversion
119 g/L
clotting during a
 Hematocrit
disorders. massage.
= .35 (35%)
 Noted that
 In our patient, 7. Review the  This is to
patient has
there is heavy records and note determine if
not voided for
blood loss certain conditions the amount
4 hours.
found in her such as retained discharged is
 Gravida 1,
 urine that placental still within the
Para 0
exceeds the fragments, any normal limits.
 Pitocin 10 u.
average laceration,
IM
normal abruptio placenta,
amount. Our etc.
patient’s
postpartum 8. Measure a 24 -  This will help
hemorrhage is hour intake and in
caused by output. Observe determining
uterine atony for signs of the fluid loss.
where the voiding difficulty. A urine output
uterus stops of 30-50 ml/hr
contracting, or more
which leads to indicates an
bleeding adequate
because the circulating
placental sites volume.
have closed. Voiding
Uterine atony difficulty may
is caused by happen with
the inability of hematomas
the in the upper
myometrium portion of the
to contract vagina
sufficiently in causing
response to pressure in
oxytocin, a the urethra.
hormone the
body releases 9. Observe for  Hematomas
before and reports of often result
during persistent perineal from
childbirth to pain or feeling of continued
stimulate vaginal fullness. bleeding from
uterine Apply laceration of
contractions. counterpressure the birth
on labial or canal.
perineal
lacerations.

10. Maintain a  This will

nothing-by-mouth prevent
status (NPO) aspiration of
while assessing gastric
client status. contents in
case that the
mental status
 is impaired
and also if a
surgical
management
is required.

11. Maintain a  The position

bed rest with an increases
elevation of the venous
legs by 20-30° return,
and trunk making sure
horizontal. a greater
availability of
blood to the
brain and
other vital
organs.
Bleeding may
be decreased
with the bed
rest.
References:

Belleza, M. RN. (2017). Postpartum Hemorrhage. Nurseslabs. Retrieved November 24, 2021, from: https://nurseslabs.com/postpartum-hemorrhage/
Armata N. (n.d.) Uterine Atony. Osmosis. Retrieved November 24, 202, from: https://www.osmosis.org/answers/uterine-atony