ASSESSMENT

DIAGNOSIS

ANALYSIS

GOALS AND OBJECTIVE After 8 hours of nursing intervention the patient will verbalized the understanding of causative factors and appropriate intervention.

INTERVENTION

RATIONALE

EVALUATION

Subjective: Bigla na lang akong dinugo as verbalized by the patient. Objective: y Bleeding episodes (excessive) Manifest body weakness

Fluid volume deficit related to active blood loss secondary to disrupted placental implantation.

Development of placenta on lower uterine segment Covers the internal cervical os Complications Hemorrhage or vaginal bleeding

y y

Establish rapport Monitor Vital signs. Assess color, odor, consistency, and amount of vaginal bleeding; weigh pads.

y

To gain patient s trust. To obtain baseline data. Provides information about active bleeding versus old blood, tissue loss and degree of blood loss. Provides information about maternal and fetal physiologic compensation to blood loss. Assessment provides information about possible infection, placenta previa or abruption. Warm, moist, bloody environment is ideal for growth

y

y

y

After 8 hours of nursing intervention, the patient was able to verbalize understanding of causative factors and appropriate interventions.

y

y

Assess hourly intake and output.

y

y

VS taken as follows: T- 36.5 C PR- 78 bpm RR-22 cpm BP- 100/70 mmHg

y

Assess baseline data and note changes. Monitor FHR.

y

y y For replacement of fluid volume loss. Position decreases pressure on placenta and cervical os. y y Assess for changes in LOC: note for complaints of thirst or apprehension. Position patient in supine with hips elevated if ordered or left lateral position. y y y Provide supplemental oxygen as ordered via ffacemask or nasal cannula @ 10-12 L/min.of microorganism. Initiate IV fluids as ordered (specify fluid and rate). Left lateral position improves placental perfusion. Intervention increases available O2 to saturate decreased hemoglobin. To detect signs of cerebral perfusion. Laboratory work provides y y y . Supports mother and child bonding.

RH and type. information about degree of blood loss. prepares for possible transfusion. Ultrasound provides info about the cause of bleeding. . etc.y Monitor laboratory works as obtained: Hgb and Hct. cross match for RBCs. Scheduled for ultrasound as ordered. urinalysis.

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