NURSING CARE PLAN

ASSESSTMENT DATA
(Subjective & Objective)
NURSING
DIAGNOSIS
(problem an
Etiolo!")
GOA#S AND
O$%E&TI'E
NURSING INTER'ENTIONS
AND RATIONA#E
E'A#UATION
Subjective:
Im still bleeding heavily after
three days of giving birth.
as verbalized by patient.
Objective:
!estlessness
"onfusion.
Irritability.
#$S ta%en as follo&s:
': ().*
+: ,--
!: ./
0p: ,--$1-
) 2 * pads $ day fully
saturated perineal pad
Ineffective tissue
perfusion related to
bleeding
3fter * hours of nursing
interventions4 the patient
&ill demonstrate
ade5uate perfusion
and stable vital signs
Independent:
6onitor amount of bleeding by
&eighing all pads. 7'o measure
the amount of blood loss.
8re5uently monitor vital signs.7
9arly recognition of possible
adverse effects allo&s for prompt
intervention.
6assage the uterus.7 'o help
e:pel clots of blood and it is also
used to chec% the tone of the
uterus and ensure that it is
clamping do&n to prevent
e:cessive bleeding.
+lace the mother in
'rendelenberg position.7
9ncourages venous return to
facilitate circulation4 and prevent
further bleeding.
+rovide comfort measure li%e
bac% rubs4 deep breathing.
Instruct in rela:ation or
visualization e:ercises
+rovide diversional activities.7
+romotes rela:ation and may
enhance patients coping abilities
by refocusing attention
;ependent:
3dminister medication as indicated <e.g
3fter * hours of nursing
interventions4the patient &as
able to demonstrate ade5uate
perfusion and stable vital signs.
6ethergine=7'o promote contraction
bleeding.
"ollaborative:
3dminister o:ygen as indicated.7
'o supply ade5uate o:ygen to the
fetus and mother and prevents
further complication.
3dminister medication as indicated <e.g
6ethergin=7'o promote contraction and
bleeding.
NURSING CARE PLAN

ASSESSTMENT DATA
(Subjective & Objective)
NURSING
DIAGNOSIS
(problem an
Etiolo!")
GOA#S AND
O$%E&TI'E
NURSING INTER'ENTIONS
AND RATIONA#E
E'A#UATION
Subjective: >
Objective :
?@asal 8laring
?!estlessness
? O. SaturationA 1* B
? delayed capillary refill A
more than ( sec.
?;ecreased Crine Output
A ,D ml$hr
?Increased Crine
"oncentration A 0ro&n
and hazy
Impaired gas e:change
r$t altered blood flo& and
decreased surface area
of gas e:change
3fter one hour of
nursing interventions4the
pt. Eill verbalize
understanding of
causative factors and
appropriate interventions
Independent:
?3ssessed vital signs 5 ,F
minutes7 +rovides baseline
data on the maternal blood loss
?6aintained bed rest or chair
rest &hen indicated. +rovide
fre5uent rest periods and
uninterrupted night time
sleep.7Systemic rest is
mandatory and important
throughout all phases of dse. to
reduce fatigue4and improve
strength.
?6onitored amt. and type of
bleeding.7+rovide objective
evidence of bleeding.
?+ositioned the mother on
her left side. 7'o promote
placental perfusion.
?!estrict vaginal
e:amination7+revents tearing
of placenta if placenta previa is
the cause of bleeding
?6onitor fetal contractions
and fetal heart rate by e:ternal
monitor.73ssess &hether labor is
present and fetal status and
e:ternal system avoids cervical
trauma.
3fter one hour of
nursing
interventions4the
patient &as able to
verbalize
understanding of
causative factors and
appropriate
interventions.
?6onitor positive attitude
about fetal outcome.7Support
mother and child bonding .
;ependent:
? +rovide psychological support4
activeG listening 5uestions or
concerns 7 to reduce an:iety
? 9ncourage ade5uate rest and
limit activities to &ithin client
tolerance
?+romote calm4 restful
environment 7 helps limit o:ygen
needs and consumptions
"ollaborative:
?3dminister o:ygen as
indicated7 +rovides ade5uate
fetal o:ygenation despite of
lo&ered maternal circulating
volume
NURSING CARE PLAN

ASSESSTMENT DATA
(Subjective & Objective)
NURSING
DIAGNOSIS
(problem an
Etiolo!")
GOA#S AND
O$%E&TI'E
NURSING INTER'ENTIONS
AND RATIONA#
E'A#UATION
Subjective : >
Objective:
?0leeding 9pisodes
? ) very saturated
perineal pads change
every . hours

?8acial l Hrimace due of
+ain or no complaint of
pain
?3bdomen soft$hard
&hen palpated
?6anifest 0ody Eea%ness
?Io& 0+ A ,--$)- mmJg
?Increased J! A ,-F cpm
?;ecreased !! A,) bpm
?;ecreased Crine
Output A ,D ml$hr
?Increased Crine
"oncentration A 0ro&n
and hazy
8luid #olume ;eficient
r$t 3ctive 0lood Ioss
Secondary to ;isrupted
+lacental Implantation
3fter eight hours of
nursing intervention
and medical
assistance4 +t. Eill
e:hibit signs of
ade5uate fluid
balance during
pregnancy
Inepenent(
?3ssessed color4
odor4consistency and amount of
vaginal bleedingK &eigh
pads7+rovides information about
active bleeding versus old blood4
tissue loss and degree of blood loss
?3ssessed hourly inta%e and
output.7+rovides information about
maternal and fetal physiologic
compensation to blood loss
?3ssessed baseline data and
note changes.7 3ssessment
provides information about possible
infection
?3ssessed abdomen for
tenderness or rigidityG if
present4measure abdomen at
umbilicus<specify time
interval=7Earm4 moist4 bloody
environment is ideal for gro&th of
microorganisms.
?3ssessed SaO.4 s%in color4
temp4moisture4 turgor4 capillary
refill<specify fre5uency=7;etecting
increased in measurement of
abdominal girth suggests active
abruption.
?3ssessed for changes in IO":
+t. has no further
vaginal
bleedingK0lood
pressure is
maintained at at least
,--$)- mm JgK +!
L,-- bpmK
CO?(-ml$hr.
note for complaints of thirst or
apprehension 7 3ssessment
provides information about blood vol.4
O.s saturation and peripheral
perfusion.
?+rovide supplemental O.as
ordered via face mas% or nasal
cannula M ,-G,.I$min.7'o detect
signs of cerebral perfusion
Intervention increases available O. to
saturate decreased hemoglobin.
?Initiate I# fluids as ordered
<specify fluid type and rate=78or
replacement of fluid vol. Ioss +osition
decreases pressure on placenta and
cervical os.
?+osition +t. In supine &ith hips
elevated if ordered or left lateral
position.7Ieft lateral position
improves placental perfusion.
Depenent(
?3dminister blood transfusion as
ordered &ith client consent.7'o
provides replacement of blood
components and volume
?6onitor closely for transfusions
reaction.7'o prevent for
+otentially lifeGthreatening allergic
reaction may result from incompatible
blood
?+rovide emotional supportK %eep +t.
and family informed of findings and
continuing plan of care.7Support and
information decrease an:iety and help
+t. 3nd family to anticipate &hat
might happen ne:t.
? +rovide a diet high in iron:lean
meats4 dar% green leafy vegetables4
eggs4 and &hole grains.7+roper diet
and vitamins replace nutrient losses
from active bleeding to prevent
anemiaGiron is a necessary
component of hemoglobin
&ollaborative(
?6onitor lab. Eor% as obtained:
Jgb NJct4 !h and type4cross
match for .units !0"s4urinalysis4
etc.7Iab. Eor% provides information
about degree of blood lossKprepares
for possible transfusion.
?Scheduled for ultrasound as
ordered.7Cltra sound provides info
about the cause of bleeding
?;etermine if +t. has any objections
to blood transfusionsGinform
physician.7+t. may have religious
beliefs related to accepting blood
products)
NURSING CARE PLAN

ASSESSTMENT DATA
(Subjective & Objective)
NURSING
DIAGNOSIS
(problem an
Etiolo!")
GOA#S AND
O$%E&TI'E
NURSING
INTER'ENTIONS
AND RATIONA#E
E'A#UATION
Subjective :G >
Objective:
G9levated 0+4 +4!
GInsomnia
G!estlessness
G;ry mouth
G;ilated pupils
+atient complains of
apprehension4
nervousness4 tension
Inability to concentrate
Sha%ing
3 n : i e t y
r $ t
s t r e s s
a n d
u n m e t
n e e d s
3fter four hours of
nursing intervention the
pt. Eill ;emonstrate a
decrease in an:iety 3.9.0.
reduction in presenting
physiological4 emotional4
and$or cognitive
manifestations of an:ietyK
and verbalization of relief
of an:iety
;ependent:
?9stablished rapport.
+rovide reassurance and
comfort.7 'o gain the trust
and cooperation of the patient.
?6onitored vital signs7
Identify physical responses
associated &ith both medical
and emotional conditions.
?Observed the clients behavior.
@ote any unusual activities.7
'his can point to the clients
level of an:iety.
?!evie&ed results of diagnostic
test. 7 'his may point to
physiological source of an:iety
?0e a&are of defense
mechanisms that the pt.
manifests. 7 It may interfere
&ith ability to deal &ith problem.
?!evie&ed coping s%ills that
&as used in the past.7'o
determine those that might be
helpful in the current
circumstance.
?+rovided accurate information
about placenta previa.7Jelps
client to identify &hat is reality
based.
3fter four hours of
nursing intervention
the manifested
decreased an:iety
390 reduced
presenting
manifestations of
an:iety and the pt.
Eas able to verbalize
a relief from an:iety
?Iist available resources or
persons4 including hotlines or
crisis managers. 7'o provide
ongoing and timely support.
?!evie& strategies4such as role
playing4 use of visualizations to
practice anticipated
events7Cseful for being
prepared in dealing &ith an:iety
provo%ing situation.
"ollaborative:
? 3dminister antiGan:iety drugs $
sedatives4 as ordered 7 Jelps
to manage the pt.
e:periencing an:iety
NURSING CARE PLAN

ASSESSTMENT DATA
(Subjective & Objective)
NURSING
DIAGNOSIS
(problem an
Etiolo!")
GOA#S AND
O$%E&TI'E
NURSING INTER'ENTIONS
AND RATIONA#E
E'A#UATION
Subjective :G>
Objective:
GEea%ness or fatigue
G9:ertional discomfort or
dyspnea
G3bnormal heart rate or
blood pressure in
response to activity
G9lectrocardiographic
changes reflecting
arrhythmia or ischemia
G +allor
3ctivity Intolerance r$t
9nforced 0ed !est
;uring +regnancy
Secondary to
+ostpartum Jemorrhage
3fter t&o hours of
nursing intervention the
pt. Eill demonstrate a
decrease in physiological
signs of intolerance 390
normal range of pt.s vital
signs.
Independent:
?9valuate actual and perceived
limitations of deficient in light of
unusual status.7 +rovides
comparative baseline and provides
information about needed
interventions regarding 5uality of life
?6onitor vital or cognitive signs4
&atch for changes of blood
pressure4heart and respiratory
rateK note s%in pallor and
cyanosis and the presence of
confusion.7 +rovides baseline data
to detect the changes due to
intolerance.
?Increase e:ercise levels
gradually4 such as stopping to
rest for ( mins. during a ,-G
minute &al% or sitting do&n to
brush hair instead of standing.7
+reserves conservation of energy
;ependent:
?+rovide positive atmosphere
&hile ac%no&ledging difficulty of
the situation of the client.7 Hives
the chance for the client to enhance
ability to participate in activities.
? 3ssist client in learning and
3fter t&o hours of
nursing
intervention the
+t.s vital signs
have returned to
normal range and
manifested
decreased
physiological
signs of activity
intolerance.
demonstrate appropriate safety
measures 7 to prevent injuries
?3ssist &ith activities and
provide clients use of
assistance devices.7'o develop
individually appropriate therapeutic
regimens.
"ollaborative:
?+romote comfort measures
and provide relief of pain7
Sustains clients motivation