ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fluid Volume At the end of Independent  Client’s pulse

 easy fatigability, Deficit secondary nursing  Assess uterine  That is to note rate is between
anxiety to Postpartum intervention, client contraction and how much 80 to 100 beats
Hemorrhage will maintain fluid lochia flow blood loss the per min and
Objective: volume at a every 2 hours. client is blood pressure
 Drop in the functional level as experiencing is 110/60
haemoglobin evidenced by and to prompt mmHg, lochia
and hematocrit individually for immediate slows to
laboratory adequate  Assess vital intervention moderate
results haemoglobin, signs and note  Changes in BP amount of flow
 Blood loss more hematocrit for peripheral and pulse may with no large
than 500 ml laboratory results, pulses. be used for clots,
 Heavy lochia stable vital signs, rough estimate hemoglobin
flow adequate urine of blood loss. level is above
 Decreased output, good skin 11g/L.
urine output turgor and capillary Collaborative  Client
 Pallor refill after one  Monitor  Helps in verbalizes
week. laboratory monitoring the understanding
studies effectiveness of of the causative
(haemoglobin the intervention; factors and
and hematocrit, malfunction in purpose of
creatinine/ BUN) the kidneys may interventions
indicate major and medication;
bleeding participates in
episodes procedures
 Advise client to  Activity may without
maintain bed predispose to hesitations;
rest and further bleeding. attentive and
schedule monitors own
activities to vital signs upon
provide assessment;
undisturbed rest and follows
periods. restrictions
 Keep fluids  To encourage applied.
 within reach of fluid intake
client.
 Teach client  To prevent
perineal self- development of
care. perineal
infections
 Administer  This drug helps
oxytocin as in the
prescribed by contraction of
physician the uterus.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for ineffective After 8 hours of Independent: After 8 hours of
Patient is still tissue perfusion nursing  Monitor amount  To measure the nursing
bleeding after a related to interventions , of bleeding by amount of blood interventions, the
week of giving birth hemorrhage. the patient will weighing all loss. patient was able to
 Restlessness demonstrate pads.  Early demonstrate
 Confusion adequate  Frequently recognition of adequate perfusion
 Irritability perfusion and monitor vital possible and stable vital
stable vital signs. signs. adverse effects signs.
Objective: allows for
 V/S taken as prompt
follows:  Massage the intervention.
T: 36.7 uterus.  To help expel
P: 107 clots of blood
R: 23 and it is also
Bp: 100/70 used to check
the tone of the
uterus and
ensure that it is
clamping down
  Place the to prevent
mother in excessive
Trendelenberg bleeding.
position.  Encourages
venous return to
facilitate
circulation, and
 Provide comfort prevent further
measure like bleeding.
back rubs, deep  Promotes
breathing. relaxation and
Instruct in may enhance
relaxation or patient’s coping
visualization abilities by
exercises. refocusing
attention.
Collaborative:
Administer oxygen
as indicated.
 To supply
adequate
oxygen to the
fetus and
Administer mother and
medication as prevents further
indicated complication.
(oxytocin)  To promote
contraction and
prevents further
bleeding.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Anxiety related to After 8 hours of Independent: After 8 hours of
 Confusion, knowledge deficit nursing  Encourage  Verbalization of nursing
 Restlessness regarding intervention, the the client and anxiety provides an intervention, the
 Patient procedures, client can or the family opportunity client is able to
displays management verbalize anxiety to identify to clarify information, verbalize anxiety
increased and disease and appear feelings of correct misconception and appears
apprehension condition as relaxed with anxiety. s relaxed with
and evidenced by stable vital  and gain perspective, stable vital signs.
uncertainty patient asks signs. facilitating the
Objective: many question problem-solving
 Pallor about the process.
VS taken as follows: disease  Stay with the  To help in maintaining
 T: 36.5 client by emotional control in
 P: 110 providing a response to the
 R: 22 calm, empathic changing physiological
 BP: 120/90 and supportive status. Helps in
attitude. lessening
interpersonal
transmission of
feelings.
 Provide  Giving accurate
information information can lessen
about the the anxiety and to
treatment identify what is reality
regimen and based.
effectiveness of
the
interventions.
 Evaluate  Changes in the vital
physiological signs may be due to
response to physiologic responses,
postpartum but they can be
hemorrhage aggravated by
psychological factors