ARON E.

NOVESTEROS N1A FUNDAMENTALS OF NURSING

Objective Data:

 Vital signs: oral temperature 36.5 degrees Celsius, noninvasive blood pressure 130/100 via
 right arm, heart rate 60 bpm and noted to be in sinus rhythm, oxygen saturations 97% on room
 air, shallow respirations 30 bpm and nonlabored.
 Patient is awake, alert and oriented to self, place, and time.
 Heart rate normal sinus rhythm, heart sounds S1, S2 with an estimated grade II systolic
 murmur auscultated.
 Lungs clear in upper lobes and diminished in bases bilaterally, equal
 expansion noted, shortness of breath accompanied with high pitch sound
 Always asleep but easily awakens
 Slow movements noted
 Needs assistance upon changing positions
 Pallor noted
 Equal bilateral weakness noted in upper and lower extremities
 Left upper extremity=5; Right upper extremity=5;
 Left lower extremity=4; Right lower extremity=2.

Nursing Diagnoses
The problem concerns the patient’s activity intolerance related to his generalized
weakness and imbalance between oxygen supply and demand as evidenced by shortness of
breath with exertion and fatigue.

Deficient Fluid Volume Related to Excessive Bleeding After Birth as Evidenced by Heavy Vaginal Bleeding

 SHORT TERM GOAL: After 8 hours of giving care to the patient the maternal blood pressure is
higher than 100/60 mmHg, pulse rate is within the normal range of 60-100 beats per minute
and flow of lochia is less than a saturated pad per hour.

 LONG TERM GOAL: After 2 days of nursing intervention the patient will be able to regain strength and
no evidence of bleeding, maintain optimal fluid balance and vital signs within normal limits.
 ASSESSMENT NURSING SCIENTIFIC INTERVENTIO RATIONALE EVALUATION
DIAGNOSIS EXPLANATION N
Subjective Deficient Normally, the
date: fluid uterus
volume continues to
related to contract after
the delivery of
excessive
the baby and
blood loss
placenta. These
as contractions
evidenced help close the
by heavy vessels that
vaginal supplied blood
bleeding, from the
hypotensio mother to the
n, baby. When
tachycardia. these
contractions do
not continue or
are not strong
enough,
hemorrhage
occurs.
Sometimes, a
tear in the
cervix, placenta,
or the blood
vessels within
the uterus may
cause
hemorrhage

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