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OBJECTIVES
INTERVENTION
RATIONALE
EVALUATION
Subjective: Verbalized, Mga ikapito q nag-kalibanga itong gabiuna ug nagsukasuka pod ko.
Fluid and Electrolyte Imbalance related to active fluid loss due to frequent loose bowel movement and vomiting
At the end of my care, the patient will maintain fluid volume as evidenced by: Vital signs within normal range: BP=110-140/60-90 mmHg
Independent: Monitor the vital signs especially blood pressure To gather baseline data
Goal partially met as evidenced by: Vital signs within normal range: T=37 C, PR=72 bpm, regular, strong, RR= 21 cpm, regular, shallow in depth, without the use of accessory muscles, BP=120/80 Verbalization of discomfort and pain
Objective: Looks tired and worn out NPO temporarily according to chart Capillary refill 2 seconds Vital Signs: BP: 100/60 mmHg
To ensure accurate picture of fluid status. Fluid replacement needs are based on correction of current deficits and ongoing losses. Promote comfort and prevent injury from dryness.
skin care with emollients Collaborative: Administer D5LR 1L to run at 44 gtts/min. Provide prompt circulatory improvement and replace fluids lost.
CUES/ EVIDENCES
NURSING DIAGNOSIS Risk for fluid volume deficit related to blood loss secondary to placental delivery
OBJECTIVES
INTERVENTION
RATIONALE
EVALUATION
Objective: NPO since 6am Mouth and lips are dry as noted. Skin snaps back within 2 seconds when pinched Gush of blood is present during the delivery of the newborn and placenta Blood loss of 350 cc Vital Signs: T=37 C, PR=72 bpm, regular, strong, RR= 21 cpm, regular, shallow in depth, without the use of accessory muscles, BP=120/80 mmHg Profuse sweating noted Laboratory Data: CBC
Within our care, the patient will be free from risk of dehydration as evidenced by: Vital signs within normal range: T=36.5 to 37.5C, PR=60 to 100 bpm, RR=16 to 20 cpm, BP=100-140/60-90 mmHg The patient will have moist lips Decreased sweating Firm fundus
Independent: Monitor vital signs and note for any significant changes
Goal met as evidenced by: Decreased BP, postural hypotension, and tachycardia are early signs of hypovolemia Provides information about the status of patients loss Indicators of dehydration and need for increased intake Boggy fundus indicates that there is absence of contraction thus risk for extensive bleeding To prevent dryness and Vital signs within normal range: T=37 C, PR=72 bpm, regular, strong, RR= 20 cpm, regular, shallow in depth, without the use of accessory muscles, BP=120/80 mmHg Lips are moist Decreased sweating Fundus is firm
Monitor for the fundus for firmness after the delivery of placenta
Hemoglobin: 11.4 gm % Hematocrit: 32gm % WBC: 10, 300/cumm Neutrophil: 80 % Lymphocyte: 14 % Monocyte: 3 % Eosinophil: 3 % Basophil: 0 % Platelet count: 313,000 T/cumm IV fluid: D5LR 1L at 10-12 gtts/min
cracking of lips
CUES/ EVIDENCES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTION
RATIONALE
EVALUATION
Risk for maternal infection related to invasive procedures and traumatized tissues secondary to birthing process.
Within our care, our patient Independent will be free from signs and Note date and symptoms of infection as time of rupture of evidenced by: membranes Vital signs within normal range : T- 36.5 C-37.5 C PR- 60-100 bpm RR- 12-20 cpm BP- 100-140/60-90 mmHg No foul odor in the perineum Absence of purulent discharges in the perineum
Objective: Vital signs: T=37 C, PR=72 bpm, regular, strong, RR= 21 cpm, regular, shallow in depth, without the use of accessory muscles, BP=120/80 mmHg
Laboratory Data: CBC Hemoglobin: 11.4 gm % Hematocrit: 32gm % WBC: 10, 300/cumm Neutrophil: 80 % Lymphocyte: 14 %
Use surgical asepsis in preparing equipment Clean perineum with sterile water
Within 4 hours after Goal met as evidenced by: rupture of membranes, the Normal vital signs: client and fetus are at T=37 C, PR=72 increased risk for bpm, regular, strong, ascending tract RR= 21 cpm, infections and regular, shallow in possible sepsis depth, without the use of accessory muscles, BP=120/80 Increased mmHg temperature or pulse greater than 100 bpm No foul odor in the may indicate perineum infection. Normal No presence of protective purulent discharges leukocytosis with in the perineum WBC count as high as 25,000/mm3 must be differentiated from elevated WBC count caused by infection. Reduces risk of contamination
Rupture of Membranes occur at 6am; received in the delivery room at 7:00 am. Dilatation of cervix measures 3 cm.