[Type text]

ECHEVARRIA, Merry Joyce A. BSN114-GRP.54A

FEU-IN Mam Leonardo
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: After 8 hours Independent: · After 8 hours

“Halos ilang of nursing of nursing
linggo na ako Risk for fluid volume interventions · Monitor amount · To measure the interventions,
nakapanganak deficit related to blood , the patient of bleeding by amount of blood the patient
pero malakas pa loss will be able to lessen weighing all loss. was able to
rin ang the amount of blood pads. demonstrate
pagdurugo ko ” loss from 300 ml to adequate
150ml. perfusion and
(I’m still bleeding · Frequently · Early recognition stable vital
heavily after weeks of monitor vital of possible signs.
giving birth) as signs. adverse effects
verbalized by allows for prompt
patient. intervention.

· Massage the · To help expel

uterus. clots of blood and
Objective: it is also used to
· Restlessness check the tone of
the uterus and
· Confusion. ensure that it is
clamping down to
· Irritability. prevent excessive
bleeding.
· V/S taken as
follows:
T: 36.8 · Place the mother · Encourages
P: 105 in Trendelenberg venous return to
R: 24 position. facilitate
Bp: 100/70 circulation, and
prevent further
· 4 pads per day bleeding.
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ECHEVARRIA, Merry Joyce A. BSN114-GRP.54A
FEU-IN Mam Leonardo

· Provide comfort · Promotes

measure like relaxation and
back rubs, deep may enhance
breathing. patient’s coping
Instruct in abilities by
relaxation or refocusing
visualization attention.
exercises.

Provide
diversional
activities.

Collaborative:

· Administer · To supply
oxygen as adequate oxygen
indicated. to the mother and
prevents further
complication.

· Administer · To promote
medication as contraction and
indicated (e.g prevents further
Pitocin, bleeding.
Methergin)