DAVAO DOCTORS COLLEGE, INC.

GEN. MALVAR ST., DAVAO CITY

COLLEGE OF ALLIED HEALTH SCIENCES | NURSING PROGRAM

Name of Patient: PATIENT MIRANDA Age: 15 Religion:

Date of Admission: SEPTEMBER 1, 2023 Sex: F Civil Status:
Chief Complaint: Extreme abdominal pain and water leakage in vagina Attending Physician: DR. CASTEEL

PROBLEM NURSING GOALS/OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNSOSIS CRITERIA INTERVENTION
Date: Risk for severe blood By the end of the 8 hours 1. Assess the client’s A review of the September 1,
September 1, 2023 loss related to labor of shift, the patient will: reproductive history menstrual history 2023; 7:00 am
secondary to anemia and prior
- Display a normal ultrasonography if “Goal Partially
Time:
Scientific basis: blood profile with applicable can Met”
2:20 AM help establish
Anemia is a blood WBC count,
hemoglobin, and gestational dating
disorder characterized The patient
Subjective Cues: coagulation studies and determine
by abnormally low displayed a normal
- Patient stated within normal limits. whether the
levels of healthy red blood profile with
“Sa una doc, pregnancy
blood cells or reduced WBC count, RBC
pero katong - The client will location is known
hemoglobin, the iron- count, and Hb
nabal-an nako na demonstrate (Hendricks et al.,
bearing protein in red count in normal
buntis ko, ako na adequate perfusion, 2019).
blood cells that range. However,
giundangan delivers oxygen to as evidenced by
2. Assess and monitor the client did not
doc.” when tissues throughout the stable vital signs, These determine
laboratory reports such still have a stable
asked about body. The most palpable pulses, the amount of
as CBC, type and vitals ad
history of common symptoms of good capillary refill, blood loss and
crossmatch, Rh titer, evidenced by RR
smoking and this disorder are usual mentation, and may provide
fibrinogen levels, having 18-23 bpm.
drinking alcoholic fatigue, weakness and, adequate urine information
beverage platelet count, APTT, regarding the
in extreme cases, output.
PT, and HCG levels. cause. Obtaining
shortness of breath or
- Patient is unsure palpitations, or you hemoglobin and
about her may have no hematocrit levels
heredo-familial symptoms at all and securing a
disease history (Sacirovic, et al., blood sample for
2023). During vaginal typing or cross-
Objective Cues: delivery or labor, it matching is
- Patient was typically involves a essential not only
diagnosed with blood loss of a to help predict the
anemia during minimum of 500 extent of blood
her 5th trimester milliliters (equivalent to loss but also to
 DAVAO DOCTORS COLLEGE, INC.
GEN. MALVAR ST., DAVAO CITY
COLLEGE OF ALLIED HEALTH SCIENCES | NURSING PROGRAM

half a liter and can lead prepare for blood

- Watcher of the to primary postpartum replacement.
patient stated hemorrhage (PPH), Hematocrit should
“Opo doc, kapila which is characterized be maintained
na siya na by the substantial loss above 30% to
hospital katong of blood within the support oxygen
1st and 2nd initial 24 hours and nutrient
month niya na following childbirth transport.
buntis kay wala (Queensland Health,
kaayo naga 2021). 3. Assess the client’s This provides
kaon. Unya nag pulse, respiration, and baseline data on
sige pud siya blood pressure every 15 maternal response
suka2x katong minutes and apply a to blood loss. With
duha-tulo blood pressure cuff, as significant blood
kabulan na iyang necessary. loss, the pulse rate
tiyan.” when and respiratory
asked about past rate will start to
medical history increase as the
heart attempts to
- “Naka compensate for
experience pud the decreased
ko doc ug circulatory volume
constipation, na and the respiratory
medyo magsakit system increases
na akong anal gas exchange to
area, ingon sa better oxygenate
midwife naa daw the RBCs.
koy
haemorrhoids.”
4. Monitor pulse Supplementary
as verbalized by
oximetry; inform the oxygen is needed
patient
healthcare provider O2 for O2 saturation of
saturation is 92% or 92% or less.
- Patient
less. Adequate oxygen
complained
about extreme delivery is a
abdominal pain product of the
and some water amount of oxygen
leakage in her in the arterial
vagina blood, represented
by the CaO₂ and
 DAVAO DOCTORS COLLEGE, INC.
GEN. MALVAR ST., DAVAO CITY
COLLEGE OF ALLIED HEALTH SCIENCES | NURSING PROGRAM

how fast that blood

- Primigravida is flowing,
represented by the
- RR: 18-23 bpm cardiac output
(Salmen et al.,
- Cervical dilation: 2016).,
3cm
5. Assess and monitor These skin
- Cervical the client’s skin for changes can
Effacement: 50% pallor or cyanosis. indicate
inadequate
- Leaking bag of oxygen delivery to
water was tissues, helping
evident healthcare
providers detect
worsening anemia
or complications
like hypoxia,
shock, or organ
dysfunction
promptly, and
guide appropriate
interventions to
prevent further
deterioration and
ensure patient
safety.

6. Monitor and record To assess the

maternal blood loss and progress of labor,
uterine contractions. detect
complications
such as
postpartum
hemorrhage, and
ensure the safety
and well-being of
both the mother
 DAVAO DOCTORS COLLEGE, INC.
GEN. MALVAR ST., DAVAO CITY
COLLEGE OF ALLIED HEALTH SCIENCES | NURSING PROGRAM

and the baby

during childbirth.

7. Anticipate the need Blood transfusion

for the transfusion of is necessary for
packed RBCs as per severe bleeding to
physician’s order. replenish the
body's lost blood
volume, restore
oxygen-carrying
capacity, maintain
vital organ
perfusion, and
prevent life-
threatening
complications
such as shock and
organ failure.

8. Educate client about To ensure their

the need for blood informed consent
transfusion and understanding
of the procedure,
potential risks, and
benefits,
empowering them
to make decisions
about their
healthcare.
Additionally, it
helps promote
patient
cooperation and
compliance with
post-transfusion
monitoring,
enhancing the
overall safety and
effectiveness of
 DAVAO DOCTORS COLLEGE, INC.
GEN. MALVAR ST., DAVAO CITY
COLLEGE OF ALLIED HEALTH SCIENCES | NURSING PROGRAM

the transfusion
process.

9. Administer fluid To maintain

replacement as per circulatory volume
physician’s order to counteract fluid
losses/shock.

10. Administer To replenish

medications such as depleted iron
iron supplements and stores and correct
folic acid as per nutritional
physician’s order. deficiencies, which
are common
causes of anemia,
ultimately aiding in
the recovery of red
blood cell
production and
improving the
patient's overall
health and vitality.
Adequate
supplementation
can also help
prevent further
complications
associated with
anemia and
support the body's
ability to recover
from blood loss.

11. Note temperature, Excessive blood

odor and color of loss with
vaginal discharge, decreased
obtain culture if hemoglobin
appropriate. increases the
 DAVAO DOCTORS COLLEGE, INC.
GEN. MALVAR ST., DAVAO CITY
COLLEGE OF ALLIED HEALTH SCIENCES | NURSING PROGRAM

client’s risk of
developing an
infection. Infection
is more likely to
occur because the
damaged tissue is
susceptible to
microbial invasion.

12. Collaborate with the A collaborative

interdisciplinary team, approach can help
including obstetricians, address the
anesthesiologists, and patient's needs
hematologists to ensure from multiple
that the patient's care angles and
plan is tailored to her provide a
specific needs and comprehensive
concerns. care plan.

REFERENCES:
Braunstein, E. M. (2022, July 6). Anemia due to excessive bleeding - Blood disorders - MSD manual consumer
version. MSD Manual Consumer Version. https://www.msdmanuals.com/home/blood-
disorders/anemia/anemia-due-to-excessive-bleeding
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse's pocket guide: Diagnoses, prioritized ANGELICA CLAIRE B. BARECUATRO, SN
interventions and rationales (16th ed.). F.A. Davis NAME OF STUDENT
Martin, P., & R.N. (2022, March 18). Nursing care plan guide for anemia.
Nurseslabs. https://nurseslabs.com/anemia-nursing-care-plans/
Martin, P., & R.N. (2022, September 9). 9 bleeding in pregnancy (Prenatal hemorrhage) nursing care plans.
Nurseslabs. https://nurseslabs.com/bleeding-in-pregnancy-prenatal-hemorrhage-nursing-care-plans/

Queensland Health. (2021). Severe bleeding after birth. Queensland Clinical

Guidelines. https://www.health.qld.gov.au/__data/assets/pdf_file/0035/706589/c-pph-
severebleeding.pdf
Sacirovic, S., Asotic, J., Maksimovic, R., Radevic, B., Muric, B., Mekic, H., & Biocanin, R. (2023). Monitoring
and prevention of anemia relying on nutrition and environmental conditions in sports. Materia Socio
Medica, 25(2), 136. https://doi.org/10.5455/msm.2013.25.136-139