3eASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION

Subjective: Acute Pain related to Short Term Goal:  Established rapport  To gain trust by the Short Term:
“Sobrang sakit sa bandang increase pressure in the After 30 mins. To 1 hour of patient After 30 mins. To 1 hour of
puson ko, pati sa likod ko” abdomen and bleeding nursing intervention the  Monitored skin color,  These are usually altered nursing intervention, the
between the uterine wall due client will report intensity of temperature and vital in acute pain. client was able to experience
Pain Scale: 9/10 to massive accumulation of pain using standardized pain signs lesser pain and above a
blood behind the placenta scale. tolerable level as manifested
secondary to premature  Evaluated degree of  Attitudes and reactions by:
Objective: separation of the placenta, Long Term: discomfort through to pain are individual and  Pain scale 5/10
 Vital Signs possibly evidenced by verbal After 4 hours of nursing verbal and non-verbal based on past  Partially met.
BP – reports of uterine tenderness intervention the client will cues experiences.
HR – and back pain with a pain manifest decrease in pain  Encouraged verbal report  Pain is highly subjective Long Term:
RR – scale of 9/10. scale of 9/10 to a during and after the and cannot be felt by  After 4 hours of
 Facial Expression of manageable level. nursing intervention others. To identify the nursing intervention,
pain/facial grimace effectiveness of the the client reported
 Irritable intervention decreased of pain
 Guarding Behavior  Obtained clients  To fully understand scale from 9/10 to
 Positioning to ease assessment of pain to client’s pain symptoms 5/10 and positive
the pain include COLDSPA verbal report of
 Pale in appearance (Characteristics, Onset, client during the
 Skin is cold to touch Location, Duration, evaluation.
 Delayed capillary Severity, Pattern,  Partially met.
refill of 4 seconds Associated Factors) of
 Uterine tenderness pain
 Counted the number of  To determine the
pads that the patient amount of blood loss
uses

 Provided comfort  Promotes relaxation and

measure like back rubs, may enhance patients
deep breathing exercise coping abilities by
refocusing.
 Positioned the client in  To enhance placental
the left lateral position, perfusion
 with the head elevated
 Encouraged client to
move slowly, bed in low
position, raised side rails
 Provide patient
education about the
condition
Collaborative:
 Administered Tramadol
50 mg/IV q6 x 6 doses as
prescribed.
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION
Subjective: Risk for altered related to the Display core temperature  Noted preoperative
use of anesthetic agent as within normal range temperature
evidence by reduction of Be free of complications such
body temperature of 35C as cardiac failure, respiratory
Objective: infection or failure,  Ascertain the type of
T- 35 C thromboembolic surgical procedure the
 Pale in appearance phenomena, and delayed client is having
healing
 Monitor the patient’s
vital signs, temperature,
LOC, watch for signs and
 Sudden movement may
anticipate risk for fall
 Help patient to feel more
informed and lessen
anxiety and stress.
 To relieve the pain of the
patient using
pharmacologic
intervention.
RATIONALE EVALUATION
 Used as baseline for
monitoring
intraoperative
temperature.
 Helps in identifying
elements of risk like
extensive surgical
procedure of any sort
with prolonged exposure
of body surfaces and long
period of anesthesia.
 Evidence supports
commencement of active
warming preoperatively
 symptoms of and monitoring it
hypothermia and take throughout the
necessary measures to intraoperative period.
keep the patient warm
throughout the
procedure.
 Assessed environmental  May assist in maintaining
temperature and modify or stabilizing patient’s
as needed: providing temperature
warming blankets,
increasing room
temperature.
 Covered skin areas  Heat losses will occur as
outside the operative skin is exposed to cool
field. environment.

 Apply warming blankets  Inhalation of anesthetics

at emergence from depress the
anesthesia. hypothalamus, resulting
in poor body
temperature regulation.
 Monitor temperature
throughout  Temperature elevation
intraoperative phase may indicate adverse
response to anesthesia.
 ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for ineffective tissue Short term:  Established rapport  To gain trust by the Short term:
“Ang dami paring perfusion related to After 30 mins. to 1 hour of patient After 30 mins. to 1 hour of
lumalalabas na dugo sa hemorrhage as evidenced by nursing interventions, the  Assessed skin color,  Helps in determining nursing interventions, the
pwerta ko” vaginal bleeding. patient will demonstrate temperature, moisture, location and type of patient was able to
adequate perfusion and and whether changes are perfusion problem. demonstrate adequate
stable vital signs widespread or localized perfusion.
Objective:  Monitor amount of  To measure the amount
 Pale in appearance Long term: bleeding by weighing all of blood loss. Long Term:
 Delayed capillary After 4 hours of nursing pads.
refill interventions the patient will  Frequently monitor vital  Early recognition of
 Restlessness verbalize understanding of signs. possible adverse effects
 Confusion risk factors or condition, allows for prompt
 irritability therapy regimen, and when intervention.
to contact health care  Evaluated reports of  To help isolate and
provider. extremity pain promptly, differentiate problems
noting any associated related to blood flow and
symptoms like cramping identify appropriate
or heaviness, discomfort interventions
with walking, progressive
temperature or color
changes.
 Measured capillary refill  To determine adequacy
of systemic circulation

 Massage the uterus  To help expel clots of

blood and it is also used
to check the tone of the
uterus and ensure that it
is clamping down to
prevent excessive
bleeding.
 Place the mother in
Trendelenburg position
 Provide comfort measure
like back rubs, deep
breathing. Instruct in
relaxation or visualization
exercise. Provide
diversional activities.
 Discussed relevant risk
factors like family history,
smoking, hypertension.
 Emphasizes need for
regular exercise program
 Encourages venous
return to facilitate
circulation, and prevent
further bleeding
 Promotes relaxation and
may enhance patient’s
coping abilities by
refocusing attention.
 Information necessary
for client to make
informed choices about
remediating risk factors
and committing to
lifestyle changes.
 To enhance circulation
and promoting general
well being