TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

CLINICAL CASE ANALYSIS

Name of Patient Pt. ICD Age: 16 Gender: F

Address Singat, Pura Tarlac Date Admitted 01-27-22
Diagnosis UTERINE ATONY

NURSING HISTORY:

Patient ICD is a single mother who resides in Gerona, Tarlac. She is a college graduate, a
Roman Catholic and was born on November 19, 2004, in Singat, Pura Tarlac. The client has
an obstetric history of G:2 T:1 P:0 A:0 L:1. The menarche of the patient is in the month of
December, year 2014 and her last menstrual period was last April 25, 2021.

Past health history

The client has no recorded family history.

History of present illness

The patient was admitted on 26th of January due to profuse bleeding as observed by the
patient's 4 fully soaked adult diapers. Aside from these, she also complained of severe pain at
the vaginal incision site and suprapubic area. As seen vital signs were taken as follows; blood
pressure 90/70 mmHg, respiratory rate of 25 bpm, pulse rate of 112 bpm, body temperature of
35.5 degrees Celsius. The patient delivered an alive baby via normal spontaneous delivery
(NSD) with an estimated gestational age of 36 weeks, an Apgar score of 8,9, birthweight of
2.3 kg, and with a head circumference of 31.9 cm. There were no abnormalities detected.
Vitamin K, BCG, and Hepatitis B vaccine were administered to the baby.

PATHOPHYSIOLOGY
BOOK-BASED PATHOPHYSIOLOGY
Source: https://www.medscape.com/answers/275038-187547/what-is-the-pathophysiology-of-postpartum-hemorrhage-pph

CLIENT-BASED PATHOPHYSIOLOGY
DIAGNOSTIC PROCEDURES

01/26/22
PHYSICAL ASSESSMENT

 (+) Profuse bleeding

 4 fully soaked adult diapers
 (+) Severe pain at the vaginal incision site and in suprapubic area.

DAY 1
01/27/22 (7:00 am)
PHYSICAL ASSESSMENT
 (+) Profuse bleeding
 12 fully soaked adult diapers (24 hrs)
 (+) Severe pain at the vaginal incision site and in suprapubic area.
 Pain scale: 8/10
VITAL SIGNS
 Blood Pressure: 90/70 mmHg
 Temperature: 35.5 °C
 Pulse Rate: 112 bpm
 Respiratory Rate: 25 bpm

COMPLETE BLOOD COUNT

A complete blood count (CBC) is a blood test. It gives the provider an information about blood and
overall health. CBCs help providers diagnose, monitor and screen for a wide range of diseases,
conditions, disorders and infections.
CBC RESULT

  NORMAL VALUES RESULT ANALYSIS

HGB 11.5-14.8 g/dl 8.7 DECREASED
HCT 0.34-0.44 % 0.3 DECREASED
RBC 4.20-5.30 x 10 12/L 2.9 DECREASED
WBC 4.50-10 .0 x 10 9/L 10 NORMAL
NEUTROPHIL 0.50-0.70% 0.51 NORMAL
LYMPHOCYTE 0.20-0.40% 0.32 NORMAL
MONOCYTE 0.03-0.08% 0.06 NORMAL
EOSINOPHIL 0.005-0.05% 0.03 NORMAL
BASOPHIL 0.00-0.01% 0.01 NORMAL
MCV 87.0- 102.2fL 99 NORMAL
MCH 25.6-31.3g/dl 31 NORMAL
MCHC 28.2-31.1g/dl 28.9 NORMAL
PLATELET CT 150-450 x 10 9/L 220 NORMAL
BLOOD TYPING: B+

INTERPRETATION
The decreased in patient’s Hemoglobin, Hematocrit, and Red Blood Cells are caused by the
blood loss during the profuse bleeding of the patient.

DAY 1
01/27/22 (6:10 pm)
VITAL SIGNS
 Blood Pressure: 90/70 mmHg
 Temperature: 36.2 °C
 Pulse Rate:102 bpm
 Respiratory Rate:22 bpm

DAY 2
01/28/22 (8:00 am)

PHYSICAL ASSESSMENT

 (+) 2 fully soaked adult diapers

  Pain scale:2/10
 (-) BT reaction
1st Unit: 8pm to 12:20am
Ongoing BT of 2nd unit
VITAL SIGNS
 Blood Pressure: 90/60 mmHg
 Temperature: 35 °C
 Pulse Rate:105 bpm
 Respiratory Rate:20 bpm

01/28/22 (6:20 pm)

 (-) BT reaction
3rd unit: 1pm to 5pm

DAY 3
01/29/22 (12 midnight)
CBC RESULT

  NORMAL VALUES RESULT ANALYSIS

HGB 11.5-14.8 g/dl 11 DECREASED
HCT 0.34-0.44 % 0.35 NORMAL
RBC 4.20-5.30 x 10 12/L 4 DECREASED
WBC 4.50-10 .0 x 10 9/L 9.8 NORMAL
NEUTROPHIL 0.50-0.70% 0.57 NORMAL
LYMPHOCYTE 0.20-0.40% 0.34 NORMAL
MONOCYTE 0.03-0.08% 0.05 NORMAL
EOSINOPHIL 0.005-0.05% 0.05 NORMAL
BASOPHIL 0.00-0.01% 0.01 NORMAL
MCV 87.0- 102.2fL 94 NORMAL
MCH 25.6-31.3g/dl 30.2 NORMAL
MCHC 28.2-31.1g/dl 28.7 NORMAL
PLATELET CT 150-450 x 10 9/L 254 NORMAL
NORMAL
INTERPRETATION
The result of CBC shows that the patient’s Hemoglobin and Red Blood cells slightly increases
from its past result but still it is not within its normal values. While the patient’s Hematocrit is now
within its normal value.

01/29/22(8:00 am)
PHYSICAL ASSESSMENT
 2 Partially soaked adult diapers
VITAL SIGNS
 Blood Pressure :100/70 mmHg
 Temperature :36.5 °C
 Pulse Rate:98 bpm
 Respiratory Rate:20 bpm

MEDICAL MANAGEMENT

Medical Date General Indication/ Nursing

Management performed/ description purpose Responsibility
changed/
discontinued
4 units of Date ordered: Transfusion of Before:
Packet red January 27, Packed red blood PRBCs is
blood cell 2022 cells are typically indicated to the -Verify
(PRBC) for given in situations patient with doctor’s order.
Blood where the patient uterine atony Inform the
Transfusion to has either lost a who had profuse client and
run for 4 hours large amount of bleeding to explain the
each unit, with blood or has compensate for purpose of the
an interval of 4 anemia that is the blood loss procedure.
hours. causing notable and provide
symptoms. additional -Check for
oxygen-carrying cross matching
capacity and and typing. To
expansion of ensure
volume. compatibility

-Obtain and
record baseline
vital signs

During:

-Practice strict
asepsis

-At least 2
licensed nurse
check the label
of the blood
transfusion.

-Warm blood at
room
temperature
before
transfusion to
prevent chills.

-Identify client
properly. Two
Nurses check
the client’s
identification.

- Use needle
gauge 18 to 19
to allow easy
flow of blood.

-Start infusion
slowly at 10
gtts/min.
Remain at
bedside for 15
to 30 minutes.

After:

-Monitor vital
signs. Altered
vital signs
indicate
adverse
reaction.
 -Do not mix
medications
with blood
transfusion to
prevent adverse
effects.

-Do not
incorporate
medication into
the blood
transfusion. Do
not use blood
transfusion
lines for IV
push of
medication.

- Never
administer IV
fluids with
dextrose.
Dextrose based
IV fluids cause
hemolysis.

-Observe for
potential
complications.
Notify
physician
IVF: D5LRS Date ordered: Lactated Ringer's Hormonal and Before:
1L + 20 units January 27, and 5% Dextrose physical -Ask for
Oxytocin x 2022 Injection, sterile, changes of consent
20gtts/min nonpyrogenic pregnancy speed -Document
solution for fluid up the loss of baseline data
and electrolyte fluids and -choose and
replenishment and electrolytes. disinfect
caloric supply in a IVF was appropriate site
single dose ordered to of IV line.
container for prevent -Prepare the
intravenous electrolytes oxytocin
administration. imbalance to the
Oxytocin is a patient. During:
hormone that is Oxytocin was -Check if drops
used to induce added to control per minute is
labor or strengthen the patient’s correct
uterine postpartum -Check if IV
contractions, or to hemorrhage. line is patent
control bleeding and not kinked.
after childbirth
After:
- Observe for
signs of fluid
overload.
-Document the
procedure.
IVF: Plain Date ordered: Normal Saline is a In transfusion, Before:
Normal Saline January 27, prescription normal saline is -Ask for
Solution 2022 medicine used for uniformly consent
(PNSS) x KVO fluid and employed, and -Document
electrolyte is the only baseline data
 replenishment for solution -choose and
intravenous compatible with disinfect
administration. blood appropriate site
Normal Saline may components. of IV line.
be used alone or Normal saline is
with other invariably the During:
medications. solution utilized -Check if drops
for initial per minute is
intravenous correct
infusions. -Check if IV
IVF was also line is patent
ordered to and not kinked.
prevent
electrolytes After:
imbalance to the - Observe for
patient as signs of fluid
hormonal and overload.
physical -Document the
changes of procedure.
pregnancy speed
up the loss of
fluids and
electrolytes.
Paracetamol Date ordered: Paracetamol The most BEFORE:
300mg IV prior January 27, exhibits analgesic common -Assess any
to BT 2022 action by approach to allergies to
peripheral blockage preventing medication.
of pain impulse Febrile non- -Consider the
generation. It hemolytic 10 rights of
produces transfusion medication
antipyresis by reaction and -Read the label
inhibiting the allergic of the
hypothalamic heat- reactions during medication
regulating center. blood when it is taken
Its weak anti- transfusion is to from the
inflammatory give the patient medication
activity is related to premedication cart.
inhibition of with an -Check the
prostaglandin antipyretic such integrity and
synthesis in the as paracetamol. expiration date
CNS. of the
medication.
-Check the IV
tubing

DURING:
-Recheck label
and dosage
before
administering.
- Recheck the
IV tubing for
its patency
AFTER:
-Assess client
for any side
effects.
-Check for the
client’s
condition;
assess and refer
immediately if
 there are any
deviations from
normal.
Hydrocortisone Date ordered: Hydrocortisone is a Before blood BEFORE:
100mg IV prior January 27, steroid medicine transfusion,
to BT 2022 that is used to treat Intravenous -Ask the
many different corticosteroids patient for
conditions, are beneficial consent
including allergic for the -Assess any
disorders, skin management allergies to
conditions, and prevention medication.
ulcerative colitis, of acute -Consider the
arthritis, lupus, anaphylactic 10 rights of
lung disorders, and transfusion medication
certain blood cell reactions. -Read the label
disorders such as of the
anemia (low red medication
blood cells) or when it is taken
thrombocytopenia from the
(low platelets) medication
cart.
-Check the
integrity and
expiration date
of the
medication.
-Make sure to
administer the
medication
before blood
transfusion.

DURING:
-Recheck label
and dosage
before
administering.
-Administer the
medication
aseptically.

AFTER:
-Assess client
for any side
effects.
-Check for the
client’s
condition;
assess and refer
immediately if
there are any
deviations from
normal.
Methergine Date ordered: Methergine Methergine is BEFORE:
0.2mg/ml IM January 27, (methylergonovine) administered in
STAT then 2022 is an ergot alkaloid the patient to -Ask the
after 2 hours that affects the help control patient for
smooth muscle of a postpartum consent
woman's uterus, bleeding cause -Assess any
improving the by uterine allergies to
muscle tone as well atony. medication.
 as the strength and -Consider the
timing of uterine 10 rights of
contractions. medication
-Read the label
of the
medication
when it is taken
from the
medication
cart.
-Check the
integrity and
expiration date
of the
medication.
-Make sure to
administer the
medication
before blood
transfusion.

DURING:
-Recheck label
and dosage
before
administering.

AFTER:
-Assess client
for any side
effects.
-Check for the
client’s
condition;
assess and refer
immediately if
there are any
deviations from
normal.
Celecoxib Date ordered: Celecoxib is a Celecoxib was Before:
200mg 1 cap January 27, nonsteroidal anti- given to the -Ask the
now then q 6 2022 inflammatory drug patient for her patient for
PRN for pain (NSAID). It works severe pain at consent
by reducing the vaginal -Assess any
hormones that incision site and allergies to
cause inflammation in suprapubic medication.
and pain in the area caused by -Consider the
body. uterine atony. 10 rights of
medication
-Assess
patient’s pain
scale before
administration.
-Read the label
of the
medication
when it is taken
from the
medication
cart.
-Check the
 integrity and
expiration date
of the
medication.

DURING:
-Recheck label
and dosage
before
administering.
-Give patient
water to
swallow.

AFTER:
-Assess client
for any side
effects.
-Check for the
client’s
condition;
assess and refer
immediately if
there are any
deviations from
normal.
Cefuroxime Date ordered: Interferes with Cefuroxime was Before:
500mg tab 1tab January 28, bacterial cell wall ordered to treat -Ask the
TID 2022 synthesis and prevent patient for
by inhibiting the infection at her consent
final step in the vaginal incision. -Assess any
crosslinking of allergies to
peptidoglycan medication.
strands. -Consider the
Peptidoglycan 10 rights of
makes the cell medication
membrane -Read the label
rigid and of the
protective. Without medication
it, bacterial when it is taken
cells rupture and from the
die medication
cart.
-Check the
integrity and
expiration date
of the
medication.

DURING:
-Recheck label
and dosage
before
administering.
-Give patient
water to
swallow.

AFTER:
-Assess client
for any side
effects.
 -Check for the
client’s
condition;
assess and refer
immediately if
there are any
deviations from
normal.
Ferrous Sulfate Date ordered: An iron supplement During BEFORE:
1 tab OD January 28, used to treat or pregnancy, the -Assess any
2022 prevent low blood volume of blood allergies to
levels of iron. Iron in pregnant medication.
is an important body increases, -Consider the
mineral that the and so does 10 rights of
body needs to their amount of medication
produce red blood iron need. Body -Read the label
cells and keeps the uses iron to of the
body in good make more medication
health. blood to supply when it is taken
oxygen to the from the
baby. If patient medication
doesn't have cart.
enough iron -Check the
stores or get integrity and
enough iron expiration date
during of the
pregnancy, they medication.
could develop -Instruct patient
iron deficiency to take ferrous
anemia. Ferrous sulfate on an
sulfate is used empty stomach,
for the at least 1 hour
prevention of before or 2
iron deficiency hours after a
anemia in the meal.
patient. - Instruct
patient to avoid
taking antacids
or antibiotics
within 2 hours
before or after
taking ferrous
sulfate.

DURING:
-Recheck label
and dosage
before
administering.
- Offer patient
water to
swallow.

AFTER:
-Assess client
for any side
effects.
-Check for the
client’s
condition;
assess and refer
immediately if
 there are any
deviations from
normal.

Calcium 1 tab Date ordered: Calcium carbonate Calcium BEFORE:

OD January 28, is a dietary supplementation -Assess any
2022 supplement used during allergies to
when the amount pregnancy is medication.
of calcium taken in associated with -Consider the
the diet is not a reduction in 10 rights of
enough. Calcium is risk of medication
needed by the body gestational -Read the label
for healthy bones, hypertension, of the
muscles, nervous pre-eclampsia medication
system, and heart. neonatal when it is taken
Calcium carbonate mortality and from the
also is used as an pre-term birth. medication
antacid to relieve cart.
heartburn, acid -Check the
indigestion, and integrity and
upset stomach. expiration date
of the
medication.
-Instruct patient
to eat before
taking the
medication.

DURING:
-Recheck label
and dosage
before
administering.
- Instruct
patient to chew
if chewable
tablet is
ordered.
- Offer patient
water to
swallow.

AFTER:
-Assess client
for any side
effects.
-Check for the
client’s
condition;
assess and refer
immediately if
there are any
deviations from
normal.
Name of Student Estabillo, Verly
Malonzo, Vince Jude
Maniego, Angelica
Pascual, Rijina Grace
Date Submitted FEBRUARY 22, C.I.’s Signature
2022
Form No.: TSU-
Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
COS-SF-04
 Prioritizing Problems

Nursing Diagnosis Rank Justification

This should be the 1st Nursing

st
Deficient fluid volume 1 priority because:
related to excessive blood  Loss of blood is number one
lost after birth reason for maternal morbidity
and maternal death around
the world. Survival needs or
imminent life-threatening
problems take the highest
priority. Appropriate
management is vital to
prevent potentially life-
threatening hypovolemic
shock. The management
goals are to treat the
underlying disorder and
return the extracellular fluid
compartment to normal,
restore fluid volume, and
correct any electrolyte
imbalances.

This is the second nursing diagnosis

Acute pain related to 2nd because:
tissue damage as  Acute pain provides a
evidenced by bleeding and protective purpose to make
pain at the perineal area. the patient informed and
knowledgeable about the
presence of an injury or
illness. The unexpected onset
of acute pain reminds the
patient to seek support,
assistance, and relief.

This is the third nursing diagnosis

Anxiety r/t lack of 3rd because:
knowledge regarding  Anxiety is a physiologic
symptoms, progression of response that can result from
condition, and treatment genetic vulnerabilities and
regimen as evidenced by
nervousness and psychosocial stressors. It can
increased pulse rate. cause feelings of dread,
apprehension, and worry in
response to a perceived fear
or stressor. Experiencing
anxiety can affect how a
patient functions on a daily
basis and responds to care..
NURSING CARE PLAN 1: DEFICIENT FLUID VOLUME
 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Deficient fluid volume After 8 hours of proper Independent: Independent: After 8 hours of proper
According to the related to excessive nursing intervention, 1. Monitor the 1. To have a baseline nursing intervention,
patient, she used 4 fully blood loss after birth. the patient’s vital signs patient’s VS every and evaluate the the patient’s vital signs
soaked adult diapers. will improve and there hour. patient’s progress if did not improve but
Scientific Explanation will be no bleeding. the bleeding stopped.
the interventions
The body initially
Objective: responds to a reduction are working AEB:
Vital Signs in blood volume with effectively. BP: 90/60 mmHg
PR: 112 beats/min increased heart and 2. Count and weigh PR: 105 beats/min
BP: 90/70 mmHg respiratory rates. These perineal pads and, 2. Weighing perineal
reactions increase the pads before and
if possible,
oxygen content of each after use and then Remarks:
12 fully soaked adult erythrocyte and cause preserve blood Goal PARTIALLY met.
clots to be subtracting the
diapers (24 hours) faster circulation of the
remaining blood. Blood evaluated by the difference is an
flow to nonessential primary care accurate technique
organs gradually stops provider. to measure vaginal
to make more blood discharge
available for vital
organs, specifically the
heart and brain. Blood 3. Measure a 24-hour 3. To help determine
flow to the brain and intake and output.
the kidneys decreases fluid loss.
Observe for signs Monitoring urine
as blood loss continues
and fluid is conserved. of voiding difficulty. output is a good
Urine output decreases gauge of blood loss
and eventually stops. because the
kidneys need
https://tinyurl.com/
sufficient arterial
39zv83ku
blood flow and
4. Instruct the patient pressure to
to avoid rapid function.
changes in position, 4. To avoid further
and encourage bed bleeding due to
rest. excessive
5. Massage the boggy movement.
uterus using one
hand and place the 5. For the uterus to
second hand above contract.
the symphysis
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, TarlacCityPhilippines 2300
Tel.no.: (045) 493-1865 Fax: (045) 982-0110 website: www.tsu.edu.ph

SOAPIE CHARTING: DEFICIENT FLUID VOLUME

Patient’s Name: Pt. ICD Case Number: 12569788
Age/sex: 16 years old / female Diagnosis (Dx): Uterine Atony
01-27-2022

8:00am S Patient reported she fully soaked 4 adult diapers.

8:15am O -Vital signs were taken and recorded as follows:

 BP: 90/70 mmHg HR: 112 beats/min
-12 fully soaked adult diaper with 24hrs.

A Deficient fluid volume related to excessive blood lost after birth.

8:20am

P
After 8 hours of proper nursing intervention, the patient’s blood pressure
8:25am will increase from 90/70 to 100/60 mm Hg and pulse rate from 112bpm to
100bpm.

8:30am I  Monitored the patient’s vital signs every hour.

 Counted and weighed perineal pads and preserved blood clots to
be evaluated by the primary care provider.
 Measured a 24-hour intake and output. Observed for signs of
voiding difficulty.
 Instructed the patient to avoid rapid changes in position, and
encourage bed rest.
 Massaged the boggy uterus using one hand and placed the
second hand above the patient’s symphysis pubis.
 Inserted another IV line: PNSS x KVO.
 Administered Paracetamol 300mg IV prior to BT.
 Given Hydrocortisone 100mg IV prior BT.
 Patient was given 3 units PRBC properly typed and crossmatched
to run for 4 hours each unit, with an interval of 4 hours.
 Administered Methergine 0.2mg/ml IM STAT then after 2 hours.

E
After 8 hours of proper nursing intervention, the patient’s blood pressure
6:35pm and pulse rate did not improve but the bleeding stopped. As evidenced by
minimal changes in her blood pressure from 90/60 mmHg to 90/60 mmHg
and 112 bpm on her pulse rate to 105 bpm, goal is parttially met.
NURSING CARE PLAN 2: ACUTE PAIN
ASSESSMENT NURSING DIAGNOSIS
Subjective: Acute pain related to After 1-2 hours of
The patient verbalized tissue damage as proper
that she is experiencing evidenced by bleeding and intervention,
pain at her vaginal pain at the perineal area.
incision site.
Pain scale: 8/10
Objective:
Vital Signs Scientific Explanation:
BloodPressure:90/70 Perineal hematomas or
mmHg extensive perineal
Temperature: 35.5 °C lacerations may cause
Pulse Rate: 112 bpm discomfort or pain for the
Respiratory Rate: 25 bpm client. If the client reports
severe pain in the perineal
area or a feeling of
•(+) Profuse bleeding pressure between her legs,
a hematoma could be
causing this. The overlying
skin is intact with no
noticeable trauma.
However, blood
accumulates underneath
from injury to blood
vessels in the perineum
during birth. They may
occur at the site of an
episiotomy or laceration
repair if a vein was
punctured during suturing.
PLANNING INTERVENTION RATIONALE EVALUATION
Independent: Independent: After 1-2 hours of
nursing 1. Monitor for the extent of 1. To monitor the presence of proper nursing
the perineal or vaginal bleeding on the laceration intervention the patient
patient will verbalize lacerations. that causes pain to the verbalized relief of pain
relief from pain and patient. and discomfort as
discomfort. evidenced by the pain
From a pain scale of 2. Inspect the patient’s 2. Pain in the perineal area scale of 2/10.
8/10 to less than perineal area for the can be a cause of
5/10. presence of a hematoma. hematoma. Remarks:
Goal met
3. Encourage the patient for 3. Relaxation techniques will
relaxation and diversional help the patient to control
activities (e.g., deep the pain. Deep breathing
breathing exercises) (e.g., exercises, back rubs, or
watching TV). diversional activities such
as watching TV or listening
to music may distract the
patient from the presence
of pain.
4. Provide comfort measures 4. Cold application can limit
such as applying an ice bleeding by reducing blood
pack into the perineum. flow to the area; cold also
numbs the area and makes
the patient feel more
comfortable.
5. Encourage the client to eat 5. High-fiber foods, such as
high-fiber foods and fruits and vegetables, can
increase fluid intake to help relieve symptoms and
avoid constipation and prevent constipation during
prevent straining. the postpartum period.
Fiber is indigestible, adds
bulk to the stool, and
stimulates bowel
movements; it also
improves digestion, helps
the woman reestablish
bowel habits, and prevents
constipation by softening
the stools without straining
and putting stress on the
suture lines. Adequate fluid
intake will help soften the
stool and ease bowel
movement, thus preventing
Dependent: constipation.
1. Administer PRN
medication for pain
Dependent:
(Celecoxib 200mg 1 1. To relief patient’s pain.
cap).
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, TarlacCityPhilippines 2300
Tel.no.: (045) 493-1865 Fax: (045) 982-0110 website: www.tsu.edu.ph

SOAPIE CHARTING: ACUTE PAIN

Patient’s Name: Pt. ICD Case Number: 12569788
Age/sex: 16 years old / female Diagnosis (Dx): Uterine Atony
01-28-2022
8:00am S The patient verbalized that she is experiencing pain at her vaginal incision
site.
Pain scale: 8/10
8:15am O -Vital signs were taken and recorded as follows:
 BP: 90/70 mmHg, Temp: 35.5 °C, PR: 112 beats/min, RR: 25
bpm
-Profuse bleeding
8:20am A Acute pain related to tissue damage as evidenced by bleeding and pain at
the perineal area.
8:25am P After 1-2 hours of proper nursing intervention, the patient will verbalize
relief from pain and discomfort. From a pain scale of 8/10 to less than
5/10.
8:30am I  Monitored for the extent of perineal or vaginal lacerations.
 Inspected the client’s perineal area for the presence of a hematoma
 Encouraged the patient for relaxation and diversional activities
(e.g., deep breathing exercises) (e.g., watching TV).
 Provided comfort measures such as applying an ice pack into the
perineum.
 Encouraged the client to eat high-fiber foods and increase fluid
intake to avoid constipation and prevent straining.
 Administered PRN medication for pain (Celecoxib 200mg 1 cap).

10:35am E After 1-2 hours of proper nursing intervention the patient verbalized relief
of pain and discomfort as evidenced by the pain scale of 2/10. Goal is
met.
.
NURSING CARE PLAN 3: ANXIETY
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Anxiety r/t lack of After 4 hours of Independent: Independent: After 4 hours of
knowledge regarding appropriate nursing appropriate nursing
"Nurse natatakot na ako 1. Review the history of labor, 1. To help identify
symptoms, progression interventions, the interventions, the
ang daming lumalabas na onset, and duration. the causes and to
of condition, and patient will be able patient was able to
dugo sa ari ko at sobrang provide proper
treatment regimen to demonstrate demonstrate relief from
sakit ng tahi ko, di ko nursing interventions.
evidenced by relief from anxiety anxiety and was able to
alam ang gagawin ko" as
restlessness. and will be able to verbalize understanding
verbalized by the patient.
verbalize 2. Maintain a calm, non- of causative factors and
understanding of 2. Anxiety is contagious purpose of individual
threatening manner while
causative factors and may be therapeutic
Scientific Explanation: working with the client.
OBJECTIVE: and purpose of transferred from interventions.
Postpartum hemorrhage individual health care provider
is one of the most severe therapeutic to client or vice versa. AEB:
 Anxious obstetric complications interventions. 3. Learning ways to “Makakayanan ko ang
 Weak appearance contributing to maternal 3. Demonstrate and encourage relax can help reduce problema na ‘to” as
 Irritability morbidity and mortality. techniques like deep anxiety. verbalized by the
A postpartum breathing exercise. patient.
hemorrhage can be a
Vital Signs:
dramatic, life-threatening • Patient is
Pain scale: 8/10 event and may occur in relaxed
the context of extreme
RR: 25 breaths/min • Improved
pain or obstetric
4. Therapeutic skills appearance
PR: 112 beats/min interventions. The client 4. Establish and maintain a
may reasonably need to be directed • Less irritability
trusting relationship by toward putting the
experience extreme listening to the client;
psychological distress client at ease, because
undermining her ability displaying warmth,
to cope. Her perception answering questions directly,
of her quality of care offering unconditional
from caregivers will acceptance; being available
likely contribute to her and respecting the client’s
postpartum recovery use of personal space.
(Thompson et al., 2011).
5. Encourage discussion about
post-discharge expectations.
6. Provide a calm, quiet, restful
environment.
7. Maintain calmness in your
the nurse who is a
stranger may pose a
threat to the highly
anxious client. GOAL MET.
5. Patient can discuss
their problem and
identify possible
solution, thus
decreases their
anxiety.
6. Anxious behavior
escalates by external
stimuli. A calm and
restful area enhances
a sense of security as
compared to a large
area which can make
the client feel lost and
panicked.
7. The client will feel
 approach to the client more secure if you
are calm and inf the
client feels you are in
control of the
situation.

8. Helps relieve anxiety.

8. Provide reassurance and
comfort measures.
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, TarlacCityPhilippines 2300
Tel.no.: (045) 493-1865 Fax: (045) 982-0110 website: www.tsu.edu.ph

SOAPIE CHARTING: ANXIETY

Patient’s Name: Pt. ICD Case Number: 12569788
Age/sex: 16 years old / female Diagnosis (Dx): Uterine Atony
01-29-2022

8:00am S "Nurse natatakot na ako ang daming lumalabas na dugo sa ari ko at

sobrang sakit ng tahi ko, di ko alam ang gagawin ko" as verbalized by the
patient.

8:15am O -Vital signs were taken and recorded as follows:

 BP: 90/70 mmHg, Temp: 35.5 °C, PR: 112 beats/min, RR: 25
bpm
-Anxious and weak appearance irritability

A
Anxiety r/t lack of knowledge regarding symptoms, progression of
8:20am condition, and treatment regimen evidenced by restlessness.

P
After 1-2 hours of proper nursing intervention, the patient will verbalize
8:25am relief from pain and discomfort.

8:30am I 

Reviewed the history of labor, onset, and duration.
Maintained a calm, non-threatening manner while working with
the client.
 Demonstrated and encouraged techniques like deep breathing
exercise.
 Established and maintained a trusting relationship by listening to
the client; displaying warmth, answering questions directly,
offering unconditional acceptance; being available and respecting
the client’s use of personal space.
 Encouraged the patient to discuss about post-discharge
expectations.
 Patient was provided a calm, quiet, restful environment.
 Maintained calmness in your approach to the client
 Patient was provided with reassurance and comfort measures.

E
After 4 hours of appropriate nursing interventions, the patient was able to
1:35pm demonstrate relief from anxiety and was able to verbalize understanding
of causative factors and purpose of individual therapeutic interventions.
As evidence by: Makakayanan ko ang problema na ‘to” as verbalized by
the patient.Patient is relaxed, improved appearance, and less irritability
Goal is met.