c.

Intervention Nursing
No DiagnosisNursing Nursing Plan
. Objectives and Intervention Rational
Criteria for
results
1. Excess fluid Fluid Balance Management of
volume is Related After done action f hypervolemia 1. Monitor weight
to regulatory or 1x24 1. Weigh your changes
mechanism hours, problem res weight every 2. Monitor changes in
interference olved withcriteria r day TTV
esults : 2. Montir TTV 3. Monitor patient
1. Maintain urine 3. Moitor edem
output innorma peripheral 4. Knowing the
l limit is appro edema balance of fluids in
priatewith age , 4. Monitor the body
and BB, intake and 5. Prevents increased
2. TD, pulse , tem output preload
peraturebody i 5. Give IV 6. Improve patient
n normal limit infusion ventilation
(Lactate 7. Prevents increased
Ringer) edema
6. Elevate the 8. Reducing fluid in the
head position body
7. Limit sodium
intake
8. Collaboration
in drug
delivery

2. Acute pain Related Pain Control Pain

to injury agents After done action Management 1. For occure scale,
nursing for2 x 15 1. Perform pain intensity and
minutes It is assessment frequency of pain
expected with PQRST 2. Avoid factors that
that patients can 2. Control can cause pain to
adapt to paindelive environmental increase
ry, with outcome factors that 3. Train mothers to be
criteria: can affect the able to control /
1. Patient can use patient's adapt to the pain
pain pain response to they feel
management discomfort 4. Monitor the results
techniques that 3. Teach pain of the interventions
are taught management that have been
2. Patients can techniques provided
control pain such as deep
breathing
 4. Monitor
patient's pain
level
2. Risk for Risk detection Management sho
shock related to After doing it actio ck: volume
hipovolemia n nursingfor 1 x 24
hours 1. TTV observat 1. Vital signs are refer
ion encefor knowingcir
the patient noexper cumstances general
ience shock with c 2. Advise patient patient
riteriaresults : for rested
3. Give 2. Get enough rest will
1. TTV status it transfusionc decrease needs ene
( no happeninc orresponding rgyand work meta
rease of ± 50 needs bolism noincrease
mmHg,no tach 3. Transfusion blood c
ycardia &temp ouldreplace fluid mi
erature in rang ssing body
e 36.5-
37.5 o C)
2. Hb 12-15 g / dl

4 Risk for infection. Infection Control Infection Control

Related to tissue After done care nurs 1. Perform 1. Helps improve
discontinuity ing for 1x4 hours it parienal hygiene, prevent the
is expected that treatment every occurrence of
there will be no 4 hours.
ascending uterine
infection with 2. Record
infections and possible
theresults criteria : it date and
 no signs of the time of sepsis. Client and fetus
infection. rupture of are susceptible to
membranes. ascending tract
3. Perform a infections and possible
vaginal sepsis
examination 2. Within 4 hours after
only if rupture of the
necessary, membranes an
using aseptic infection will occur
techniques .
3. Repeated vaginal
4. Monitor
examination increases
temperature,
pulse and white the risk of endometrial
blood cells. infection.
5. Use surgical 4. Increased temperature
asepsis or pulse> can signal
techniques in infection.
equipment 5. Used with caution
preparation. Re because the use of
duces the risk antibiotics can
of stimulate excessive
contamination
growth of the
organism resistant
 .
Collaboration:
1. Give antibiotics
as indicated. .