NURSING CARE PLAN

Cues Nursing Rationale Goal/ Expected Intervention Rationale Evaluation

Diagnosis Outcome

Subjective: Fluid volume Stress After 16 hours Independent: Independent: After 16 hours of
deficit related ↓ of nursing 1. Monitor vital signs, 1. Changes in vital signs nursing intervention,
“I felt weakness to excessive ↑ production of intervention, the compare with patient may be used for rough the patient was able
all over my body” blood loss as FSH & Estrogen patient will be normal or previous estimate of blood to:
as verbalized by ↓ readings. loose
evidenced by able to:
the patient. Hyperexcitability 2. Note patient’s 2. Symptomatology may 1. Demonstrate
vaginal of uterine muscles individual be useless in gauging
bleeding, 1.Demonstrate improve fluid
↓ physiological severity or length of
Objective: pallor. Severation and improve fluid response to bleeding bleeding episode. balance as evidenced
damage to blood balance as such as weakness, 3. Provide guidelines by stable vital signs,
• Pallor vessels evidence by restlessness and for fluid replacement. good skin turgor.
• 1 day vaginal ↓ stable vital pallor. 4. Activity increases
bleeding Detachment of the signs, good skin 3. Monitor intake and intrabdominal - Goal partially met-
• Unable to rise placenta turgor. output. pressure and can
on bed ↓ 4. Maintain bed rest. predispose to further
• Poor skin turgor Vaginal bleeding Schedule activities to bleeding.
• V/S ↓ provide undisturbed
T: 36.5˚C Blood loss rest periods. Dependent:
P: 80bpm
R: 24cpm Dependent: 1. Fluid replacement is
BP: 100/70mmHg dependent on the duration
1. Blood transfusion. of bleeding. Volume
2. Monitor Hb, Hct, expanders may be infused
RBC count. until type and cross –
match can be completed
and blood transfusions
begun.
2. Aids in establishing blood
replacement needs and
monitoring the
effectiveness.