Anette Katrin B.

Cabalfin
Name of Student: _________________________________ BN2F – G1
Section and Group number: _______________________

Assessment Cues Ms. Carol Therese C. Casiple, RN, MN

Nursing Diagnosis (Rationale)
NURSING
Desired
CARENursing
PLANIntervention OB Ward
Justification Evaluation
Pathophysiologic / Outcome
Schematic Diagram
Subjective: Nursing Diagnosis: The nurse will manage 1. Assess the uterine fundus every 1.With uterine atony, a boggy - Maternal blood
The patient verbalizes: “I Deficient Fluid Volume regular and minimize 15 minutes for the first hour or relaxed uterus will not pressure is higher than
First Vital
don’t feel good. I feel dizzy related to excessive uterine postpartum bleeding. postpartum; every 30 minutes the control bleeding by 100/60 mmHg.
signs
and I have abdominal pain. bleeding after birth changes  Patient will maintain second hour postpartum; every compression of the uterine
- mechanical taking
Can I take any medication a blood pressure  hour for third and fourth hour, and muscle fibers.
events
for pain?”. Patient Definition: - endocrine of at least100/60 mm every shift thereafter; evaluate. 2. Massage stimulates the - Pulse rate is within
continues to complain of Deficient Fluid Volume is Atony - changes Hg. • Height (level of the umbilicus uterine muscle to contract. the normal range of
pain and dizziness and defined as: Decreased inability of  Patient will maintain after delivery), Size (when 3. Unnecessary massage can 60-100 beats per
continues to be restless. intravascular, interstitial, the uterus a pulse rate between contracted, should be about the cause pain and muscle fatigue, minute.
and/or intracellular fluid. to contract
Tissue 70-90 bpm. size of a large grapefruit) and with subsequent uterine
Objective: This refers to dehydration, - retained  Patient will have a Consistency (should feel firm). relaxation. - Flow of lochia is less
T: 36.8 C water loss alone without tissue preventsbalanced 24- 4. Careful vital sign than a saturated pad
P: 80 bpm change in sodium. uterus from hour intake and 2. If the uterus is relaxed or monitoring provides accurate per hour. After 30
contracting relaxing, massage it with firm but
R: 18 output. evaluation of hemodynamic mins
BP: 120/70 Trauma  Patient will have a gentle circular strokes until it status. - Patient has a
May be related to: - laceration
cognitive status within contracts. 5. Continuous seepage of balanced 24-hour
- Excessive blood of the
T: 37.1 C loss after birth cervix, expected range. blood with a firm uterus can intake and output.
P: 120bpm vagina or  Patient will have a 3. Avoid routine massage or over indicate cervical or vaginal
-
R: 28 perineum. lochia flow of less than massaging the uterus. lacerations. Bleeding after the - Improvement in the
BP: 90/60 -extensions one saturated perineal first 24 hours can indicate fluid balance as
at CS. or 4. Monitor blood pressure and
- Uncontrolled uterine Thrombin
pad per hour. retained placental fragments observed by good
bleeding rupture - blood clots  Patient will
pulse every 15 minutes for 1 hour, or subinvolution capillary refill,
- Decreased blood (example: demonstrate then every 30 minutes for the next 6. Weighing the perineal pads adequate urine
pressure episiotomy) improvement in the hour, and then once every hour will allow the nurse to output, and skin
- Increased heart fluid balance as until the mother’s condition determine the amount of turgor.
rate Source/Reference POSTPARTUM
evidenced by a good stabilizes. Continue to monitor as blood loss.
HEMMORHAGE
- Decreased RBC NANDA: capillary refill, needed. 7. Placing the woman in a side
count adequate urine 5. Monitor perineal blood loss. lying position will allow the
Carpenito, L. J. (2014).
Nursing diagnosis: Reference: output, and skin
6. Save all perineal pads used
nurse to make sure that no
Strength: application to clinical turgor. blood is pooling underneath
Members of the during bleeding and weigh them. the patient.
practice (14th ed.). Wolters
family and husband. Kluwer Lippincott Williams
7. Place the woman in a side lying
&Wilkins.
Weakness: position.
Financial problems.
Name of CI: _______________________________ ______ Area of Exposure: _______________________________