College of Allied Health Sciences

School of Nursing

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

Postpartum hemorrhage
Subjective Data: (PPH) due to uterine Short Term Goals: After 4 hours of Nurses’
atony. shift, the patient has:
The patient has verbalized ● After 4 hours of
that she had an Nursing Independent Intervention ● Patient has
spontaneous vaginal Intervention, the ● Monitor vital sign ● Close monitoring verbalized reduced
delivery with episiotomy patient/ client will: closely. of vital signs and conntrol
and she delivered a specially blood bleeding
healthy baby girl. Hence ● The client will pressure, heart
she feel fatigued and verbalize reduced rate, respiratory The goal has been meet
happy after delivering the and control rate is crucial to
baby and on the bleeding assess the
otherhand she feel a
patient's
moderate perineal pain Long Term Goals: hemodynamic
which is expected after
status. Changes in
the episiotomy repair. ● After 24 hours of vital signs may
Nursing
About 2 hours after indicate the
Intervention, the
delivery, The patient severity of
patient/ client will:
begins to complain of bleeding and guide
increased vaginal bleeding ● The Client will the need for
and feels lightheaded. The have a stabilized additional
patient reports a condition and will interventions.
sensation of dizziness restore normal ● Patient has shown
when attempting to stand
or change positions. She hemadynamic ● Initiate uterine sign of uterine
describes the bleeding as parameters and massage to promote contraction and
heavier than expected avoid additional contraction. ● Uterine massage reduced bleeding
and expresses concern complications. stimulates the
about the amount of uterine muscles, The goal has been meet
blood she is passing. promoting
contraction and
Objective Data: preventing uterine
● Blood Pressure: atony, which is a
90/60 mmHg common cause of
(decreased from postpartum
pre-delivery hemorrhage.
baseline) Massage helps the
● Heart Rate: 120
uterus to regain
bpm (elevated ● Patient
tone and control
from pre-delivery ● Encourage Skin-to- understood and
baseline) Skin Contact and bleeding. demonstrated
● Respiratory Rate: Breastfeeding. ● Encouraging skin- compliance about
22 breaths per to-skin contact and the concept of
minute initiating skin-to-skin
● Temperature: breastfeeding can contact and
98.6°F (37°C) stimulate the breastfeeding.
● Abdomen is soft, release of
non-tender uterus endogenous The goal has been meet
at or just below oxytocin. This
the level of the natural oxytocin
umbilicus.
release enhances
● Episiotomy site
uterine
intact, moderate
contractions,
bleeding noted
from the vaginal aiding in the
prevention of
 area. postpartum
● Uterine atony hemorrhage.
observed. The
uterus is not well-
contracted and Dependent Intervention ● Both oxytocin and ● Patient has
feels boggy on ● Administer oxytocin misoprostol are presented
palpation. or misoprostol to improvement in
uterotonic
stimulate uterine uterine
medications that
contractions. contraction and
aim to prevent or the bleeding
treat uterine decreases.
atony, a leading
cause of
postpartum The goal has been meet
hemorrhage.

● Order and Interpret

Laboratory Tests. ● The patient
● Valuable
laboratory results
information on the
extent of blood are all in the
loss, coagulation normal or
status and need acceptable
for blood products findings.
can be obtained
from laboratory The goal has been meet
tests such as
complete blood
counts CBC in
addition to
coagulative profile
 and typing. Further
decisions on
treatment and
management will
be guided by this
information.
Collaborative Intervention
● Notify the healthcare
provider for further ● The Client
management, which presented a
● It is necessary to
may include stabilized
communicate condition and does
additional uterotonic
swiftly with the avoid other
medications, blood
health care complication.
transfusion, and
provider so as to
possible surgical
coordinate and The goal has been meet
interventions.
manage
postpartum
haemorrhage
effectively. If the
first intervention is
insufficient,
additional
uterotonic
medicines may
need to be
administered.
Blood transfusion
may be necessary
to address anemia,
 and surgical
interventions such
as uterine artery
ligation or
hysterectomy may
be considered in
severe cases.

Name: ________________________________________________________________ Section: ______________________ Date: ________________________