DANDAN, Margareth Joy A.

BSN 2B3

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective Data: Inadequate tissue Short term goal: Independent: Short term goal:
“Two days na po perfusion related to After 3 hours of 1. Establish rapport. 1. To gain the client’s After 3 hours of
after kong manganak hypovolemia as nursing intervention trust and nursing intervention
and bigla po akong evidenced by the client’s vital signs cooperation. the client’s vital signs
nakaramdam ngayon severe vaginal will be 110/80 2. Monitor vital signs 2. To assess for is 110/80 mmHg.
ng sobrang pananakit bleeding, severe mmHg. and labs for arterial hypovolemic shock
po ng aking tiyan and abdominal pain, blood gases, and and decreased tissue Long term goal:
meron din po akong paleness of the Long term goal: hematocrit and perfusion. After 3 days of
malakas na skin, pallor, weak, After 3 days of hemoglobin levels. nursing intervention
pagdurugo.” As changes in vital nursing intervention 3. Monitor the amount 3. To measure the the client displays
verbalized by the signs, and changes the client will display of bleeding by amount of blood loss. hemodynamic
client. of level of hemodynamic weighing all the pads stability as evidenced
consciousness. stability as evidenced that are used. by stabled vital signs,
Objective Data: by stable vital signs 4. Place the client in 4. To encourage venous arterial blood gases
 Severe within normal range, Trendelenburg return to facilitate labs showed no signs
vaginal appropriate blood position. circulation and of acidosis,
bleeding. gases, adequate prevent further hemoglobin and
 Severe hemoglobin and bleeding. hematocrit were
abdominal hematocrit level. 5. Maintain bed rest and 5. Activity may within normal range.
pain. schedule activities to predispose to further
 Weak provide undisturbed bleeding.
palpable rest periods.
pulses. 6. Keep fluid within 6. To encourage fluid
 BP: 100/70 reach of client. intake.
mmHg. 7. Health teaching 7. To prevent the
 HR: 122 bpm. regarding perineal development of
 RR: 32 bmp. self- care. perineal infections.
 Extremely
 pale. Collaborative:
 Pallor and 1. Administer 2-3 L 1. To keep SpO2 >95%.
weak. oxygen via nasal
 Drowsiness. cannula.
2. Administer fluids, 2. To rapidly sustain
electrolytes, colloids, circulating volume,
blood products, as electrolyte balance,
indicated. and prevent shock
state.