CEBU TECHNOLOGICAL UNIVERSITY

In consortium with
CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

LEVEL II CCMC-CN
AY 2020-2021

NAME:DE CASTRO, SEAN PATRICK B. YEAR AND SECTION: LEVEL II-B

SUBJECT/AREA: MATERNAL AND CHILD WEEK & DATE: WEEK 3, 04/14/21
HEALTH NURSING

MODULE 5: WOMAN AFTER BIRTH: POSTPARTUM COMPLICATIONS

Learning Activity.

1. Formulate one (1) Nursing Diagnosis for the following disorders.

a.) Thromboembolic Disorders

Nursing Diagnosis: Impaired gas exchange related to decreased lung perfusion caused by
embolic obstruction of pulmonary arterial blood flow as evidenced by chest pain and low
level of oxygen saturation

b.) Puerperal Infection

Nursing Diagnosis: Ineffective breastfeeding related to inflammation of breast tissue as

evidenced by presence of pain in left breast

c.) Subinvolution of the Uterus

Nursing Diagnosis: Fluid volume deficit related to excessive blood loss as evidenced by
sudden drop in blood pressure

d.) Mood Disorders

Nursing Diagnosis: Self-care deficit related to inadequate social support as evidenced by

constant fatigue and lack of interest in daily activities.

2. Write the procedures for fundal massage with the rationale.

Fundal Massage
Purpose: To stimulate uterine contraction, promote uterine tone and consistency, and
minimize the risk of hemorrhage.
 PROCEDURES
1.) Explain the necessity for the
procedure and provide privacy.
2.) Ask client to void (unless bleeding is -An empty bladder prevents displacement
extensive and more rapid action
seems necessary). Ask her to lie
supine with knees flexed.
3.) Put on gloves. Place one hand on the
abdomen just above the symphysis
pubis. Place the other hand around
the top of the fundus.
4.) Rotate the upper hand to massage
the uterus until it is firm, being
careful not to overmassage
5.) When the uterus is firm, press the
fundus between the hands using
slight downward pressure against the collected in the uterine cavity.
lower hand.
RATIONALE
-Explanations are given to help decrease
anxiety, and privacy to enhance self-
esteem.
of the uterus and ensures accurate
assessment of uterine tone.
-Proper positioning enhances visualization
and effectiveness of procedure.
-This is to anchor the lower uterine
segment and allows to locate and assess
the fundus.
- Massage should be done only when the
uterus is not firm, and aggressive massage
may lead to a partial or complete uterine
prolapse.
- Gently squeezing with downward
pressure helps to expel blood or clots
 6.) Remove and observe the woman’s -This helps to assess the degree of
perineum for the passage of clots bleeding.
and the amount of bleeding.

7.) Massage the uterus one more time to
be certain it remains firm, cleanse
the perineum, and apply a clean
perineal pad. Discard gloves and
soiled pads according to agency
policy
8.) Document the results of the
procedure. Continue to assess the
fundus and lochia according to
agency policy. Notify the primary
care provider if the fundus does not
remain firm or if bleeding continues
- This helps to promote comfort and
hygiene while reducing the risk for
infection.
-Documentation provides a means for
evaluation. Continued assessment allows
for early identification and prompt
intervention with additional measures,
such as oxytocin, to prevent hemorrhage.

REFERENCES:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans:
Guidelines for individualizing client care across the life span (10th ed.). Philadelphia:
F.A. Davis.

Pillitteri, A. (2013). Maternal & child health nursing: Care of the childbearing &
childrearing family. Lippincott Williams & Wilkins.