ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: Risk for ineffective tissue After 8 hours of Monitor amount of To measure the After 8 hours of
perfusion related to nursing bleeding by amount of blood nursing
Im still bleeding after hemorrhage. interventions, the weighing all pads. loss. interventions, the
weeks of giving birth, as patient will patient was able to
verbalized by the patient. demonstrate Frequently monitor Early recognition of demonstrate
adequate perfusion vital signs. possible adverse adequate perfusion
Objective: and stable vital effects allows for and stable vital
signs. prompt signs.
Restlessness intervention.
Confusion
Irritability Massage the To help expel clots
V/S taken as uterus. of blood and it is
follows: also used to check
the tone of the
T: 36.8 uterus and ensure
P: 105 that it is clamping
R: 24 down to prevent
BP 100/70 excessive bleeding.

Place the mother in Encourages venous

Trendelenberg return to facilitate
position. circulation, and
prevent further
bleeding.

Provide comfort Promotes

measure like back relaxation and may
rubs, deep enhance patients
breathing. Instruct coping abilities by
in relaxation or refocusing
visualization attention.
exercises. Provide
 diversional
activities.

Collaborative:
Administer oxygen To supply adequate
as indicated. oxygen to the fetus
and mother and
prevents further
complication.

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