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Nursing Diagnosis 1. Fluid volume deficit related to vaginal bleeding.

Goal : Prevent dysfunctional bleeding and improve fluid volume.

Interventions and Rationale :


1. Advise patients to sleep with feet higher, while the body remained supine.
R / : With feet higher will increase the venous return , and allowing the blood to
the brain and other organs.

2.Monitor vital signs.


R / : Changes in vital signs when bleeding occurs more intense.

3.Monitor intake and output every 5-10 minutes.


R / : Change the output is a sign of impaired renal function.

4. Evaluation of the urinary bladder.


R / : Full urinary bladder prevents uterine contractions.

5. Perform uterine massage with one hand and the other hand placed above the
simpisis.
R / : Uterine massage stimulate uterine contractions and helps release the
placenta, one hand above simpisis prevent inversion uterine.

6. Limit vaginal and rectal examination.


R / : Trauma that occurs in the vagina and rectum increases the incidence of
bleeding was greater, in case of laceration of the cervix / perineal, or there is a
hematoma.
When the blood pressure decreases, pulse became weak, small and fast, the
patient feels sleepy, more intense bleeding, immediate collaboration.

Nursing Diagnosis 2. Ineffective tissue perfusion related to vaginal bleeding.

Goal : Vital signs and blood gases within normal limits.

Interventions and Rationael :


1. Monitor vital signs every 5-10 minutes.
R / : Changes in tissue perfusion causing changes in vital signs.

2. Note the discoloration of the nail, lip mucosa, gums and tongue, skin
temperature.
R / : With vasoconstriction and relationship to vital organs, circulation in
peripheral tissues is reduced, causing cyanosis and cold skin temperature.
3. collaboration :
Monitor blood gas levels and pH (changes in blood gases and pH levels are a
sign of tissue hypoxia)
Give oxygen therapy (oxygen transport is needed to maximize circulation to
tissue).

Nursing Diagnosis 3. Anxiety / Fear related to changes in circumstances or the


threat of death.

Goal : The client can verbalize anxiety and said anxiety is reduced or lost.

Interventions and Rationael :


1. Assess the client's psychological response to the post- childbirth bleeding.
R / : Perceptions of client influence the intensity of anxiety.

2. Assess the client's physiological responses (tachycardia, tachypnea, shaking).


R / : Changes in vital signs lead to changes in the physiological responses.

3. Treat the patient calm, empathetic and supportive attitude.


R / : Provide emotional support.

4. Provide information about care and treatment.


R / : Accurate information can reduce the anxiety and fear of the unknown.

5. Help clients identify a sense of anxiety.


R / : The expression can reduce feelings of anxiety.

6. Assess the client's coping mechanisms used.


R / : Prolonged Anxiety can be prevented with proper coping mechanisms.

Pain related to uterine cramping and possible procedures.