NAME:

AGE:

CUES NURSING DIAGNOSIS OBJECTIVES NURSING RATIONALE EVALUATION

INTERVENTION

Subjective: General: Independent: Independent: Goal met: After 8 hours

“Sobrang sakit ng tiyan ko at Ineffective tissue perfusion To facilitate the maintainance of 1. Assess patient’s vital 1. For baseline data. of nursing intervention
nagdugo ako” as verbalized related to excessive blood regulatory mechanism and function signs, O2 saturation, 2. These conditions may the patient verbalizes
by the patient. loss secondary to and skin color. indicate decreased and demonstrate the
premature separation of 2. Monitor for cerebral perfusion. normal sensations and
Objective: placenta. Specific: restlessness, anxiety, 3. To obtain data about movements appropriate.
+ Vaginal Bleeding  After 8 hours of nursing hunger and changes renal perfusion and
Abdominal pain intervention the Patient will in LOC function and the  The patient now
Abdominal rigidity verbalizes or demonstrates 3. Monitor accurately extent of blood loss. identifies factor
T-37 normal sensations and movement I&O 4. To determine the that improve
P-92 bpm as appropriate. 4. Assess uterine severity of the circulation.
R-22 brpm irritability, placental abruptio  Patient exhibits
Bp-100/60 mmhg  Patient identifies factors that abdominal pain and and bleeding growing tolerance
Pain scale:7/10 improve circulation rigidity. 5. To determine to activity.
 Patient exhibits growing 5. Assess skin color, peripheral tissue
tolerance to activity. temperature, perfusion
moisture, turgor, like hypervolemia.
capillary refill 6. Uterine pressure can
6. Teach patient not to cause pooling of
apply uterine venous blood in lower
pressure extremities