NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Postpartum After 8 hours of Independent:

Risk for Ineffective hemorrhage is nursing • monitor amount of • To measure the
tissue perfusion defined as a loss of interventions patient bleeding by weighing amount of blood loss.
related to blood in the will be able to:
all pads
postpartum period
hemorrhage as • Frequently monitor • Early recognition of
of more than 500 • Demonstrate
evidenced by: mL. The average, vital signs adverse effects allows
adequate
spontaneous perfusion. for prompt
Subjective Cues: vaginal birth will • Demonstrate interventions.
“Pira na kaadlaw an typically have a 500 stable vital
ak pag anak pero cge mL blood loss. In signs • Massage the uterus • To help expel clots of
la ghap it pag cesarean births the blood and it is also
dinugu.e haak”, as average blood loss used to check the tone
verbalized by the rises to 800-1000
of the uterus and
patient. mL. There is a
greater risk of
ensure that it is
hemorrhage in the clamping down to
first 24 hours after prevent excessive
Objective: bleeding.
the birth, called
· Restlessness
· Confusion.
primary postpartum • Place the mother in
· Irritability.
hemorrhage. A Trendelenberg • Encourages venous
secondary position return to facilitate
· V/S taken as
hemorrhage occurs circulation, and
follows:
after the first 24 prevent further
T: 36.8C
hours of birth. In
P: 90bpm bleeding.
the majority of
R: 24cpm
cases the cause of
Bp: 100/70mmhg
hemorrhage is
uterine atony, • Provide comfort • Promotes relaxation
meaning that the measures like back and may enhance
uterus is not rubs, deep breathing. patient’s coping
contracting enough Instruct in relaxation abilities by refocusing
to control theplacental or visualization attention.
site. exercise. Provide
Other reasons for a
divers ional activities.
hemorrhage would
include retained
placental fragments Collaborative • To supply adequate
(possibly including • Administer oxygen as oxygen and prevents
a placenta accreta),
indicated. further complication.
trauma of some
form, like a cervical
laceration, uterine • To promote
inversion or even • Administer contraction and
uterine rupture, and medication as prevents further
clotting disorders. indicated. (e. g bleeding.
Methergin)
MCH pp.416 by Pilliterri
vol. 1
NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Fear related to It is difficult for a After 8 hours of Indpendent: • To establish trust and After 8 hours
outcome of woman who has nursing • Listen actively and showing interest. of nursing
pregnancy after experienced bleeding intervention the focus on the patient intervention
episode of placenta late in pregnancy to patient will be able discussed her the patient
previa bleeding wait for the baby to to: personal feelings. is relaxed
come to term, • To demonstrate and shows a
Subjective cues: wondering if her • appear • Use appropriate support. good
“ Nahadlok ako mam infant will be alright. relaxed touch with patient’s response
nga mawara na liwat Most likely she is • level of permission and
ini na ak baby kay experiencing severe anxiety be • For relaxation participates
ikaduha ko na unta ini emotional stress. She reduced to • Instructed deep well in the
hiya”, as verbalized cannot help but manageable breathing exercise. activitiesl.
by the patient. wonder if the next level • To avoid confusion and
bleeding will kill her, • discusses • Speak in brief easy to understand.
Objective cues: the infant or both. concerns statements using
• looks pale She may become so with nurse simple words.
• disturbed sleep worried about the and other
• anxious safety of her child. health care Collaborative:
providers
MCH pp 415 by • Give sedatives as * To lessen excitement,
Pillitteri vol. 1 ordered. nervousness and
irritation.