ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

“Halos ilang
linggo na ako
nakapanganak
pero malakas pa
rin ang
pagdurugo ko ”
(I’m still bleeding
heavily after weeks of
giving birth) as
verbalized by
patient.

Objective:

• Restlessness

• Confusion.

• Irritability.

• V/S taken as
follows:

T: 36.8
P: 105
R: 24
Bp: 100/70






Risk for
ineffective tissue
perfusion related
to hemorrhage.
Postpartum
hemorrhage is
defined as a loss of
blood in the
postpartum period
of more than 500
mL. The average,
spontaneous
vaginal birth will
typically have a 500
mL blood loss. In
cesarean births the
average blood loss
rises to 800-1000
mL. There is a
greater risk of
hemorrhage in the
first 24 hours after
the birth, called
primary postpartum
hemorrhage. A
secondary
hemorrhage occurs
after the first 24
hours of birth. In
the majority of
cases the cause of
hemorrhage is
uterine atony,
meaning that the
uterus is not
contracting enough
to control the
bleeding at the

• After 8 hours
of nursing
interventions
, the patient
will
demonstrate
adequate
perfusion
and stable
vital signs.
Independent:
• Monitor amount
of bleeding by
weighing all
pads.
• Frequently
monitor vital
signs.




• Massage the
uterus.










• Place the mother
in Trendelenberg
position.





• Provide comfort
measure like
back rubs, deep
breathing.
Instruct in
relaxation or
visualization
exercises.

• To measure the
amount of blood
loss.

• Early recognition
of possible
adverse effects
allows for prompt
intervention.


• 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.



• Encourages
venous return to
facilitate
circulation, and
prevent further
bleeding.


• Promotes
relaxation and
may enhance
patient’s coping
abilities by
refocusing
attention.


• After 8 hours
of nursing
interventions,
the patient
was able to
demonstrate
adequate
perfusion and
stable vital
signs.
placental site.
Other reasons for a
hemorrhage would
include retained
placental fragments
(possibly including
a placenta accreta),
trauma of some
form, like a cervical
laceration, uterine
inversion or even
uterine rupture, and
clotting disorders
Provide
diversional
activities.

Collaborative:
• Administer
oxygen as
indicated.





• Administer
medication as
indicated (e.g
Pitocin,
Methergin)





• To supply
adequate oxygen
to the fetus and
mother and
prevents further
complication.


• To promote
contraction and
prevents further
bleeding.

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