NURSING

ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION

INTERVENTIONS

Subjective Data: Short Term Goals:

Objective Data: Long Term Goals:

Patient's Name: Kristine Age: 28 years Gravida: 2, Para: 1 (G2P1) Gestational Age: 39 weeks Delivery: Vaginal delivery with episiotomy Medical History: Uncomplicated pregnancy, no known bleeding disorders
Kristine was admitted to the maternity ward for the delivery of her second child. She had a normal pregnancy and went into labor spontaneously. The labor and delivery were uneventful, and she delivered a healthy baby
girl weighing 3.5 kg. Kristine reports feeling fatigued but happy after the delivery. She mentions moderate perineal pain, which is expected after the episiotomy repair. About 2 hours after delivery, Kristine begins to
complain of increased vaginal bleeding and feels lightheaded. She reports a sensation of dizziness when attempting to stand or change positions. She describes the bleeding as heavier than expected and expresses concern
about the amount of blood she is passing.