NAME: CRISHA ANN BACUTA YEAR&SECTION: BSN-2

Assesment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective Short term: Independent: Short Term:
“ pila na ka adlaw tissue After 8  Monitor vital signs  Changes in tissue Goal was met. After 8
tapos ko panganak perfusion hours of every 5-10 minutes. perfusion causing hours of nursing
pero gina dugo ko related to nursing changes in vital signs. intervention, the patient
gyapon” vaginal intervention,  Monitor blood gas  Changes In blood gases able to demonstrate
bleeding the patient levels and pH. and pH levels are a sign of adequate perfusion.
Objective: as will  Give oxygen therapy. tissue hypoxia.
 Irritability evidenced demonstrate  Oxygen transport is need Long Term:
 restlesness by adequate to maximize circulation to Goal was met. After 1
Vital Signs: fluctuation perfusion .  Monitor the amount tissue. week of nursing
T- 37 ˚C of vital of bleeding by  To measure the amount intervention, the patient’s
BP- 130/ 90 mmHg signs. Long term: weighing all pads. of blood loss. vital signs were at normal
Pr: 75 Bpm After 1 week  Massage the uterus.  To help expel clots of range.
RR- 20 Bpm of nursing blood and it is also used
intervention, to check the tone of the
the patient’s uterus and ensure that it
vital signs is clamping down to
and blood prevent excessive
gases will be  Provide comfort like bleeding.
within deep breathing.  To promote relaxation.
normal limit.
Dependent: Dependent:
 Administer oxytocin as  To promote contraction
indicated by the and prevents further
physician. bleeding.

Collaborative:
 Antibiotic therapy.
Collaborative:
 To prevent infection or
may be needed for an
infection that causes or
contribute haemorrhage.