NURSING CARE PLAN

Patient’s Initials: P.N Chief Complaint: Dizziness and Heavy Vaginal Name of Student Nurse:
Age & Gender: 42 yrs. Old/ Female Bleeding related to Active Labor as manifested by
Postpartum

Birthdate: March 05, 1979 Admitting Diagnosis: Pregnancy 40 weeks of Level/Block/Group:

gestation. Full Term Labor. G5P4004
Address: Hospital/Area:
The Medical City/ Birthing Facility
Date of Confinement: Clinical Instructor:
Date: 5/02/2021

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Data:  Uterine atony,  After 30  Explain the  Helps to Goals met, the
is a serious minutes of necessity for decrease nursing intervention
 “Hilong hilo na within 30 minutes
condition that nursing the procedure anxiety, and
po ako tapos can occur after intervention of fundal providing privacy had managed and
sobrang daming childbirth. It , the massage and enhances self- handled the uterine
dugong lumabas occurs when patient’s provide privacy esteem atony process
sa ari ko, bakit the uterus fails blood successfully by:
 Ask patient to  An empty
ganon“as to contract pressure void (unless bladder prevents
verbalized by the -Maternal blood
after the and heart bleeding is displacement of
patient pressure is higher
delivery of the rate remain extensive and the uterus and
than 100/60 mmHg.
Objective Data: baby, and it within usual more rapid ensures
can lead to a defined action seems accurate -Pulse rate is within
 Heavy Vaginal potentially life- limits; lochia necessary). assessment of the normal range of
Bleeding threatening flow is less  Ask her to lie uterine tone. 60-100 beats per
 Tense and Rigid condition than one supine with  Proper minute.
Uterus known as saturated knees flexed. positioning
 Facial Grimace postpartum perineal enhances -Flow of lochia is
 Put on gloves.
 Dizziness hemorrhage. pad per visualization and less than a
Place one hand
 With a pain scale  Full term labor hour effectiveness of saturated pad per
on the
of 6/10. occurs when a procedure. hour.
abdomen just
  Asymptomatic baby born above the  This anchors the “Nagiging okay
anemia with an between 37 symphysis lower uterine nadin ako” as
H/H=10/30.3 weeks and 42 pubis. Place segment and verbalized by the
 Hemoglobin: weeks. the other hand allows you to patient with no
10.5  around the top locate and signs facial grimace
 Hematocrit: 31.1 of the fundus. assess the and dizziness and
 WBC: 12,000   Rotate the fundus. states that she is in
 Platelets: upper hand to  Massage should good condition
218,000   massage the be done only because of a
uterus until it is when the uterus successful
firm. Being is not firm, and intervention.
careful not to aggressive
Vital Signs taken:
over massage. massage may
 BP- 140/90  When the lead to a partial
mmHg uterus is firm, or complete
 HR- 115 bpm pressure the uterine prolapse.
 RR- 22 cpm fundus  Gently
 Temp- 38.5 between the squeezing with
degrees Celsius hands using downward
slight pressure helps
downward to expel blood or
pressure clots collected in
NURSING DIAGNOSIS
against the the uterine cavity
lower hand.  This helps to
 Remove and assess the
 Deficient fluid observe the degree of the
volume related woman’s bleeding
to excessive perineum for  This helps to
blood loss after the passage of promote comfort
birth clots and the and hygiene
amount of while reducing
bleeding risk for infection.
 Massage the  To provide
uterus one accurate data.
more time to be Continue
certain it assessment
remains firm, allows for early
cleanse the identification and
perineum, and prompt
apply a clean
 perineal pad. intervention with
Discard gloves additional
and soiled pads measures, such
according to as oxytocin to
agency policy. prevent
 Bimanual hemorrhage
compression is
necessary
when fundal
massage and
administration
of uterotonics
Case Scenario Patient: Patty Noble 

Mrs. Patty Noble is a 42-year-old G5P4004 who was admitted in active labor at 38+2 weeks and just had a spontaneous vaginal delivery 30 minutes
ago. The delivery was uncomplicated, and she had no lacerations. She is approximately 30 minutes postpartum and has just called out because
she feels dizzy and has noticed more bleeding.  

Patient Information: 
▪ The patient has no significant past medical history. 
▪ She has no known drug allergies. 
▪ Her pregnancy was uncomplicated except for asymptomatic anemia with an H/H=10/30.3 and was on iron BID during her prenatal course. 

 Laboratory Data (On Admission): 

▪ Hemoglobin: 10.5 
▪ Hematocrit: 31.1
▪ WBC: 12,000 
▪ Platelets: 218,000  

Delivery Information: 
▪ Measurement of cumulative blood loss (as quantitative as possible) from the delivery was 400cc.
 ▪ The placenta was inspected at the time of delivery and appeared to be intact per the delivery note. 
▪ The vaginal vault and perineum were inspected; no lacerations were found 
▪ The infant weighed 4220 grams. 
▪ The patient has an IV line in place with oxytocin running.