ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Deficient fluid After 6 hours -Administer -to increase After 6 hours
Data: volume r/t of nursing oxygen as the amount of of nursing
>Cold, Clammy active fluid intervention ordered oxygen. intervention
and pale skin loss as the patient the patient
> Blood evidence by will able to able to reach
pressure: signs and reach normal normal vital
70/40mmhg symptoms vital signs -Administer -To provide for signs
>Pulse Rate: blood replacements
120/bpm transfusion as therapy
> Capillary order
refill of 10
seconds --Administer -To help
>HGB 5g/dl 0.9% NaCl as maintain a
ordered patient's
hydration

-Monitor vital -to detect

signs acute
transfusion
reactions

-Encourage -To prevent

patient to limit trauma in the
straining with linings in the
bowel rectum
movements
ASSESSMENT DIAGNOSIS PLANNING INTERVETION RATIONALE EVALUATION
Ineffective After 8 hours -Assess for -Particular cluster After 8 hours of
Objective tissue of nursing signs of signs and nursing intervention
data: perfusion intervention decreased symptoms occur the client  maintain
related to the client tissue with differing maximum tissue
Blood hypovolemia will maintain perfusion causes. Evaluation perfusion to vital
pressure: maximum provides a baseline organs, as evidenced
70/40mmhg tissue for future by warm and dry
perfusion to comparison skin, vitals within
Pulse Rate: vital organs, patient’s normal
120/bpm as evidenced -Assess for -Restlessness and range
by warm and rapid changes anxiety are early
Capillary refill dry skin, or continued signs of cerebral
of 10 seconds vitals within shifts in hypoxia while
patient’s mental status confusion and loss
HGB 5g/dl normal range of consciousness
occur in the later
Vaginal stage
bleeding
-Assess -Capillary refill is
Capillary refill slow and
Skin is cold sometimes absent
and pale,
conjunctivae
and lips were -Observe for -Nonexistence of
also pale pallor , peripheral pulse
cyanosis, must be reported
mottling, cool or managed
or clammy immediately.
skin. Assess Systemic
quality of vasoconstriction
every pulse. resulting from
reduced cardiac
output may be
manifested by
diminished skin
perfusion and loss
of pulses.
Therefore,
assessment is
required for
constant
comparisons

-Provide -Oxygen is
oxygen administered to
therapy if increase the
indicated amount of oxygen
 carried by available
hemoglobin in the
blood

-Administer -Sufficient fluid

IV fluids as intake maintains
ordered adequate filling
pressures and
optimizes cardiac
output needed for
tissue perfusion

-Monitor - Reduced intake or

intake, unrelenting nausea
observe may consequence
changes in in lowered
urine output. circulating volume,
Record urine which negatively
specific affects perfusion
gravity as and organ function.
necessary Hydration status
and renal function
are revealed by
specific gravity
measurements.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective data: Risk for fetal Short term: -Assess level of -To determine Within 30
distress Within 30 consciousness of what minutes of
secondary to minutes of the mother appropriate intervention the
Blood pressure: uterine rupture intervention the interventions team skillfully
70/40mmhg team must should be given and continuously
skillfully and monitored fetal
Pulse Rate: continuously -To be able to well being
120/bpm monitor fetal well -Assess the assess and throughout
being throughout degree of fetal provide the best pregnancy, labor
Capillary refill of pregnancy, labor distress care to the and delivery
10 seconds and delivery patient

HGB 5g/dl
-Assess the need -if the client is in
Vaginal bleeding for immediate active labor and
delivery cannot be
Skin is cold and stopped,
pale, emergency
conjunctivae and cesarean
lips were also delivery may be
pale indicated.

Note odor and -This can rule

color of amniotic out other
fluid potential
complications
such as
meconium
staining.

-Document -This will clarify

prognosis and and evaluate the
changes patient more.

-Provide client -Allows them to

and family understand the
teaching situation