NURSING CARE PLAN ASSESSTME

NURSING CARE PLAN

ASSESSTMENT DATA
(Subjective & Objective) NURSING DIAGNOSIS
(problem and Etiology) GOALS AND OBJECTIVE NURSING INTERVENTIONS
AND RATIONALE EVALUATION
Subjective:

” I’m still bleeding heavily after three days of giving birth.”
as verbalized by patient.

Objective:

• Restlessness
• Confusion.
• Irritability.
• V/S taken as follows:
T: 36.8
P: 100
R: 24
Bp: 100/70
• 6 – 8 pads / day fully saturated perineal pad
Ineffective tissue perfusion related to bleeding After 8 hours of nursing interventions, the patient will demonstrate adequate perfusion and stable vital signs Independent:
• Monitor amount of bleeding by weighing all pads. (r)To measure the amount of blood loss.
• Frequently monitor vital signs.(r) Early recognition of possible adverse effects allows for prompt intervention.
• Massage the uterus.(r) To help expel clots of blood and it is also used to check the tone of the uterus and ensure that it is clamping down to prevent excessive bleeding.
• Place the mother in Trendelenberg position.(r) Encourages venous return to facilitate circulation, and prevent further bleeding.
•Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises
Provide diversional activities.(r) Promotes relaxation and may enhance patient’s coping abilities by refocusing attention
Dependent:
•Administer medication as indicated (e.g Pitocin, Methergine)(r)To promote contraction and prevents further bleeding.
Collaborative:
•Administer oxygen as indicated.(r) To supply adequate oxygen to the fetus and mother and prevents further complication.
•Administer medication as indicated (e.g Pitocin, Methergin)(r)To promote contraction and prevents further bleeding.
After 8 hours of nursing interventions,the patient was able to demonstrate adequate perfusion and stable vital signs.
NURSING CARE PLAN

ASSESSTMENT DATA
(Subjective & Objective) NURSING DIAGNOSIS
(problem and Etiology) GOALS AND OBJECTIVE NURSING INTERVENTIONS
AND RATIONALE EVALUATION Subjective: Ø

Objective :

>Nasal Flaring

>Restlessness

> O2 Saturation= 78 %

> delayed capillary refill = more than 3 sec.

>Decreased Urine Output = 19 ml/hr

>Increased Urine Concentration = Brown and hazy Impaired gas exchange r/t altered blood flow and decreased surface area of gas exchange After one hour of nursing interventions,the pt. Will verbalize understanding of causative factors and appropriate interventions Independent:
>Assessed vital signs q 15 minutes(r) Provides baseline data on the maternal blood loss
>Maintained bed rest or chair rest when indicated. Provide frequent rest periods and uninterrupted night time sleep.(r)Systemic rest is mandatory and important throughout all phases of dse. to reduce fatigue,and improve strength.
>Monitored amt. and type of bleeding.(r)Provide objective evidence of bleeding.
>Positioned the mother on her left side. (r)To promote placental perfusion.
>Restrict vaginal examination(r)Prevents tearing of placenta if placenta previa is the cause of bleeding
>Monitor fetal contractions and fetal heart rate by external monitor.(r)Assess whether labor is present and fetal status and external system avoids cervical trauma.
>Monitor positive attitude about fetal outcome.(r)Support mother and child bonding .
Dependent:
> Provide psychological support, active- listening questions or concerns (r) to reduce anxiety
> Encourage adequate rest and limit activities to within client tolerance
>Promote calm, restful environment (r) helps limit oxygen needs and consumptions
Collaborative:
>Administer oxygen as indicated(r) Provides adequate fetal oxygenation despite of lowered maternal circulating volume After one hour of nursing interventions,the patient was able to verbalize understanding of causative factors and appropriate interventions.
NURSING CARE PLAN

ASSESSTMENT DATA
(Subjective & Objective) NURSING DIAGNOSIS
(problem and Etiology) GOALS AND OBJECTIVE NURSING INTERVENTIONS
AND RATIONAL EVALUATION Subjective : Ø

Objective:
>Bleeding Episodes
> 6 very saturated perineal pads change every 2 hours

>Facial l Grimace due of Pain or no complaint of pain

>Abdomen soft/hard when palpated

>Manifest Body Weakness

>Low BP = 100/60 mmHg

>Increased HR = 105 cpm

>Decreased RR =16 bpm

>Decreased Urine Output = 19 ml/hr
>Increased Urine Concentration = Brown and hazy Fluid Volume Deficient r/t Active Blood Loss Secondary to Disrupted Placental Implantation After eight hours of nursing intervention and medical assistance, Pt. Will exhibit signs of adequate fluid balance during pregnancy Independent:
>Assessed color, odor,consistency and amount of vaginal bleeding; weigh pads(r)Provides information about active bleeding versus old blood, tissue loss and degree of blood loss
>Assessed hourly intake and output.(r)Provides information about maternal and fetal physiologic compensation to blood loss
>Assessed baseline data and note changes.(r) Assessment provides information about possible infection
>Assessed abdomen for tenderness or rigidity- if present,measure abdomen at umbilicus(specify time interval)(r)Warm, moist, bloody environment is ideal for growth of microorganisms.
>Assessed SaO2, skin color, temp,moisture, turgor, capillary refill(specify frequency)(r)Detecting increased in measurement of abdominal girth suggests active abruption.
>Assessed for changes in LOC: note for complaints of thirst or apprehension (r) Assessment provides information about blood vol., O2s saturation and peripheral perfusion.
>Provide supplemental O2as ordered via face mask or nasal cannula @ 10-12L/min.(r)To detect signs of cerebral perfusion Intervention increases available O2 to saturate decreased hemoglobin.
>Initiate IV fluids as ordered (specify fluid type and rate)(r)For replacement of fluid vol. Loss Position decreases pressure on placenta and cervical os.
>Position Pt. In supine with hips elevated if ordered or left lateral position.(r)Left lateral position improves placental perfusion.
Dependent:
>Administer blood transfusion as ordered with client consent.(r)To provides replacement of blood components and volume
>Monitor closely for transfusions reaction.(r)To prevent for
Potentially life-threatening allergic reaction may result from incompatible blood
>Provide emotional support; keep Pt. and family informed of findings and continuing plan of care.(r)Support and information decrease anxiety and help Pt. And family to anticipate what might happen next.
> Provide a diet high in iron:lean meats, dark green leafy vegetables, eggs, and whole grains.(r)Proper diet and vitamins replace nutrient losses from active bleeding to prevent anemia-iron is a necessary component of hemoglobin
Collaborative:
>Monitor lab. Work as obtained: Hgb &Hct, Rh and type,cross match for 2units RBCs,urinalysis, etc.(r)Lab. Work provides information about degree of blood loss;prepares for possible transfusion.
>Scheduled for ultrasound as ordered.(r)Ultra sound provides info about the cause of bleeding
>Determine if Pt. has any objections to blood transfusions-inform physician.(r)Pt. may have religious beliefs related to accepting blood products.
Pt. has no further vaginal bleeding;Blood pressure is maintained at at least 100/60 mm Hg; PR <100 bpm;
UO>30ml/hr.
NURSING CARE PLAN

ASSESSTMENT DATA
(Subjective & Objective) NURSING DIAGNOSIS
(problem and Etiology) GOALS AND OBJECTIVE NURSING INTERVENTIONS
AND RATIONALE EVALUATION Subjective :- Ø
Objective:
-Elevated BP, P,R
-Insomnia
-Restlessness
-Dry mouth
-Dilated pupils
Patient complains of apprehension, nervousness, tension Inability to concentrate
Shaking
Anxiety r/t stress and unmet needs After four hours of nursing intervention the pt. Will Demonstrate a decrease in anxiety A.E.B. reduction in presenting physiological, emotional, and/or cognitive manifestations of anxiety; and verbalization of relief of anxiety Dependent:
>Established rapport. Provide reassurance and comfort.(r) To gain the trust and cooperation of the patient.
>Monitored vital signs(r) Identify physical responses associated with both medical and emotional conditions.
>Observed the clients behavior. Note any unusual activities.(r) This can point to the clients level of anxiety.
>Reviewed results of diagnostic test. (r) This may point to physiological source of anxiety
>Be aware of defense mechanisms that the pt. manifests. (r) It may interfere with ability to deal with problem.
>Reviewed coping skills that was used in the past.(r)To determine those that might be helpful in the current circumstance.
>Provided accurate information about placenta previa.(r)Helps client to identify what is reality based.
>List available resources or persons, including hotlines or crisis managers. (r)To provide ongoing and timely support.
>Review strategies,such as role playing, use of visualizations to practice anticipated events(r)Useful for being prepared in dealing with anxiety provoking situation.
Collaborative:
> Administer anti-anxiety drugs / sedatives, as ordered (r) Helps to manage the pt. experiencing anxiety
After four hours of nursing intervention the manifested decreased anxiety AEB reduced presenting manifestations of anxiety and the pt. Was able to verbalize a relief from anxiety
NURSING CARE PLAN

ASSESSTMENT DATA
(Subjective & Objective) NURSING DIAGNOSIS
(problem and Etiology) GOALS AND OBJECTIVE NURSING INTERVENTIONS
AND RATIONALE EVALUATION Subjective :-Ø

Objective:

-Weakness or fatigue
-Exertional discomfort or dyspnea
-Abnormal heart rate or blood pressure in response to activity
-Electrocardiographic changes reflecting arrhythmia or ischemia
– Pallor Activity Intolerance r/t Enforced Bed Rest During Pregnancy Secondary to Postpartum Hemorrhage After two hours of nursing intervention the pt. Will demonstrate a decrease in physiological signs of intolerance AEB normal range of pt.’s vital signs. Independent:
>Evaluate actual and perceived limitations of deficient in light of unusual status.(r) Provides comparative baseline and provides information about needed interventions regarding quality of life
>Monitor vital or cognitive signs, watch for changes of blood pressure,heart and respiratory rate; note skin pallor and cyanosis and the presence of confusion.(r) Provides baseline data to detect the changes due to intolerance.
>Increase exercise levels gradually, such as stopping to rest for 3 mins. during a 10-minute walk or sitting down to brush hair instead of standing.(r) Preserves conservation of energy
Dependent:
>Provide positive atmosphere while acknowledging difficulty of the situation of the client.(r) Gives the chance for the client to enhance ability to participate in activities.
> Assist client in learning and demonstrate appropriate safety measures (r) to prevent injuries
>Assist with activities and provide clients’ use of assistance devices.(r)To develop individually appropriate therapeutic regimens.
Collaborative:
>Promote comfort measures and provide relief of pain(r) Sustains clients motivation
After two hours of nursing intervention the Pt.’s vital signs have returned to normal range and manifested decreased physiological signs of activity intolerance.