IPP - first 24 hrs after delivery

“Indi mag pa dede sa bata kay nakapoy sa”

Uterus -

Oras nga nag bata - 4 hrs = Damo damo nag gwa nga dugo

Father nag abot - nag dala ice pack

Ms helen: pano ma bal an nga nag contract ang uterus? - palpate, kun nag contract - ga tig a na
sa
“ diri sa dalom sang akon pus. On ga sakit kun ma hikap kamo da”
- Kay may episiotomy, patient: ndi ang sa dalom sang pus on gd.
6x nag changes pads - damo unod

[assess if fully soaked]

- Shows damo gd tuod, C.I mentioned: ma ilis gd diaper

Sakit ang lower abdomen = (bladder distention)

BP - 90/60
Wala ka pangihi - halin sa pag bata (4hrs)

- Gin addan ulunan ang sa may ulo kay daw ma lumos sha kuno

Sakit ang pus.on again

Ms. helen had health teaching - how to salod the ihi

Takson ang ihi.. Thru cup - (observed: ms helen not ready with the materials)

5th child - G5 P5

Humok ang pus.on

Indi mag pa dede - (nga amo ni maka pa help contract uterus)

Prepare: washeild for DR for evacuation (ma kwa ang ihi kag kis a may bilin2)
 Pamatyagan puno pero indi kapangihi

Reassessed BP: 90/50

Prepare for DR (gin ready ang wheelchair)

PHYSIOLOGIC BEHAVIORAL
CUES PROBLEM PRIORITY
ACTUAL POTENTIAL ACTUAL POTENTIAL

Subjective
cues: ● Hypotens ● Bladder ● Impaired
ion distention urinary
“Nakapoy ko elimination
mag breastfeed ● Severe related to
sa akon baby” Hypogast ● Hypotens urine retention
ric pain ion verbalized by
“ Damo damo “kay pagbata
nag guwa na ● Bladder ko wala ko
dugo” distentio ● Blood kapangihi”
n Loss secondary to
“Sa dalom gid postpartum.
sang pus’on ko ● Heavy
among kasakit vaginal ● Decreased
mag hikap bleeding cardiac output
kamo da” related to low
● Extreme blood
“Waay pa ko tiredness pressure
kapangihi halin secondary to
pag bata” ● Ineffectiv postpartum.
e
“Daw malumos Breastfe ● Deficient fluid
ko sa kanipison eding volume
sng akon related to
ulunan” blood loss
secondary to
● Hypogastric postpartum.
pain w/ scale
of 8/10

Objective
cues:

● BP: 90/60 -
90/50

● Vaginal
 bleeding
evidence by
6 perineal
pads w/ full
discharge.

● Bladder
distention (4
hrs ago after
delivery)

Laboratory
Result:

● CBC
Hematocrit
Hemoglobin

Overview:
Patient __, G5P5,
Initial BP: 90/60
4hrs upon labor
IPP 24 hrs after delivery
Refusal to breastfeed infant causing less contraction of the uterus
Verbalized pain below the “pus-on”. Rate of pain: 8/10.
Lower Abdominal Pain due to Bladder Distention.
Number of pads changed: 6 pads changed for 4 hours
Large amount of lochial discharge
Lochia discharge: Heavy Lochia with presence of blood clots
Verbalized failure to eliminate urine
Performed fundal massage. Findings: soft lower abdomen (pus-on), no contraction of uterus
BP reassessed: 90/50
Patient is prepared for Evacuation in DR

Procedure/Intervention done:
1. Taking Blood Pressure.
 2. Encourage patient to perform breastfeeding help for contraction of uterus and to lessen
the bleeding
3. Performed fundal massage. For uterine contraction assessment.
4. Provided additional pillow. For upper body elevation.
5. Bed Pan is placed beside the patient. For urine output.
6. Encouraged the client to perform breastfeeding as it helps in the contraction of the
uterus.
7. Provided Ice pack to be applied on the patients hypogastric region area
8. Provided additional pads and binder for the client to use.
9.
10.

Medication:
https://docs.google.com/document/d/1ZXS2jZyWOgZaTClFZfniePPNXos5dZOsKKRptVw
Ayl8/edit

● Tranexamic Acid
● Mefenamic Acid

Laboratory:
None
Estimating Lochia Pads : (Heavy) 80mL per pads ????????????????????

Request for CBC

Total Blood Output: 98 mL?????

Proposed procedure: (by the doctor & staff)

Catheterization - for urine elimination
Preparation of patient for DR for Evacuation - for removal of any remnants during labor in the
uterus