ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective Data Deficit fluid After 8 hours Pre-operative Care After 8 hours of
volume related of nursing Independent: nursing intervention
The patient was to excessive intervention the patient was
conscious but looks blood loss. the patient Assess and document the To know the actual unable to normalize
pale. will blood loss blood loss and to her blood volume
normalize determine the and show unstable
her blood appropriate treatment vital sign. She was
V/S taken as follows: volume, needed by the patient. announced dead 3
show October 2013 at
BP: 80/60mmHg improvemen 11:45 pm due to
HR: 71 bpm t in her fluid Review the records and This will help in retained placenta,
RR: 12 cpm balance as note certain conditions determining the hypovolemic shock
evidenced such as retained placental management of the secondary to severe
by a good fragments, any laceration, situation thus anemia.
capillary abruptio placenta, etc. preventing further
refill and complications.
stable vital
signs.
Monitor the Vital Signs and Increased heart rate,
check for capillary refill. low blood pressure,
cyanosis, delayed
capillary refill indicates
hypovolemia and
impending shock.
Decrease fluid volume
of 30-50% will reflect
changes in the blood
pressure.
Massage the uterus. 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 Encourages venous
Trendelenberg position. return to facilitate
circulation, and prevent
further bleeding.
Provide comfort measure Promotes relaxation
like back rubs, deep and may enhance
breathing. Instruct in patient’s coping
relaxation or visualization abilities by refocusing
exercises. attention.
Collaborative:
Start 1 or 2 IV infusion(s) of This is important for
isotonic or electrolyte fluids rapid or multiple
with an 18-gauge catheter infusions of fluids or
or via a central venous line. blood products to
Administer fresh whole increase circulating
blood or other blood volume and enhance
products (e.g., platelet clotting. Note: Each
concentrate, plasma, unit of whole blood
cryoprecipitate) as increases the
indicated hematocrit level by
three percentage
points.
Administer medication as To promote contraction
indicated (e.g Pitocin, and prevents further
Methergin) bleeding.
Post Operative Care
Independent:
Monitor the vital signs To rule out for shock.
(pulse, blood pressure,
respiration) every 30
minutes for the next 6
hours or until stable.
Palpate the uterine fundus. To ensure that the
uterus remains
contracted.
Check for excessive lochia. To determine if the
amount discharged is
still within the normal
limits.
Collaborative:
Continue infusion of IV To maintain the
fluids as indicated. patient’s hydration,
electrolyte and blood
sugar level.
Transfuse blood as
indicated. To replace the blood
that is lost through
surgery and the
patient’s bleeding.
