G.

Nursing Care Management

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Objective: Acute pain related to After 8 hours of Independent: • To measure the After 8 hours of
• Abdominal collection of blood nursing • Monitor amount of amount of blood loss. Nursing
guarding. between uterine wall interventions, the bleeding by weighing all • Changes in location interventions, the
• Muscle and placenta. patient will pads. or intensity is not patient was able to
tension. demonstrate use • Investigate pain reports, uncommon but may demonstrate use of
• Irritability. of relaxation skills, noting location, duration, reflect developing relaxation skills, other
Vital Signs: other methods to intensity, and charact. complications. methods to
• T: 37.3 promote comfort. • Monitor maternal VS • Early recognition of promote comfort.
• PR: 95 and fetal heart rate possible adverse
• RR: 22 through continuous effects allow for
• BP: 100/70 monitoring. prompt intervention.
• Measure and record • Fundal height may
fundal height. increase with
• Position mother in the concealed bleeding.
left lateral position, with • To enhance
the head of the bed placental perfusion.
elevated. • Promotes relaxation
• Provide comfort and may enhance
measure (back rubs, deep patient’s coping
breathing, and relaxation) abilities by refocusing.