NURSING CARE PLAN

“Client with Postpartum Hemorrhage”

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Interventions
Objective Data: Risk for fluid Short term goal: Independent: Client’s pulse is
volume deficit In 2 days of nursing Assess uterine It is the most between 80 to 100
 Blood loss related to intervention the Client contraction and effective in halting beats per min and
more than postpartum will maintain fluid lochia flow every 2 bleeding especially blood pressure is
500 ml hemorrhage. volume at a functional hours. an extremely atonic 110/60 mmHg,
 Heavy level as evidenced by uterus lochia slows to
lochia flow individually adequate moderate amount
 Increased hemoglobin, Assess vital signs Changes in BP and of flow with no large
temperature hematocrit laboratory and note for pulse may be used clots, uterus is firm
due to results, stable vital peripheral pulses. for rough estimate and hemoglobin
uterine signs, adequate urine of blood loss. level is above
infection output, good uterine Postural 11g/L.
predisposin contractility, good skin hypotension
g to uterine turgor and capillary reflects a decrease Client verbalizes
atony refill after one week. in circulating understanding of
 Elevation of volume. the causative
pulse rate Long term goal: factors and purpose
indicating Client will have of interventions and
hypovolemia absence of Note client’s That is to note how medication;
 Sudden complications. physiologic much blood loss participates in
drop in response to blood the client is procedures without
blood loss. experiencing and to hesitations;
pressure prompt for attentive and
implying immediate monitors own vital
hemorrhage intervention. signs upon
 Pain in the assessment and
perineal follows restrictions
sutures Maintain bed rest Activity may applied.
and schedule predispose to
 Decreased
activities to provide further bleeding.
uterine
undisturbed rest
 contractility periods.
 Drop in the
hemoglobin Keep fluids within
and reach of client. To encourage fluid
hematocrit intake
laboratory Teach client
results perineal self- care. To prevent
 Decreased development of
urine output perineal infections.
 Pallor, easy Encourage client to
fatigability, do Kegel’s It helps improve the
anxiety exercises every 4 blood supply in the
hours. perineal area.

Collaborative or
Interdisciplinary
Data:
Keep accurate
record of subtotals Fluid replacement
of solutions/ blood with isotonic
products during crystalloid solutions
replacement depends on the
therapy. degree of
hypovolemia and
duration of
bleeding.

Administer fluids/
volume expanders Potential exists for
as indicated. over transfusion of
fluids, especially
when volume
expanders are
given prior to blood
transfusion.
Replace blood
products as Fresh whole blood,
ordered by the platelets and fresh
physician. frozen plasma are
usually given to
patients depending
on severity of blood
loss.

Administer
methylergonovine This drug helps in
as prescribed by the contraction of
the physician. the uterus.

Monitor laboratory
studies %Helps in
(hemoglobin and monitoring the
hematocrit, effectiveness of the
creatinine/ BUN) therapy;
malfunction in the
kidneys may
indicate major
bleeding episodes.
Assist in the
preparation for Symptomatology
surgery specifically may be useful in
hysterectomy. gauging severity of
bleeding episode.
 NURSING CARE PLAN
“Client with Imbalanced nutrition”

Assessment Nursing Planning Nursing Interventions Rationale Evaluation

Diagnosis
Objective Data: Short term goal: Independent: Appropriate Goal met as
Imbalanced Render nursing measures will be evidenced by:
 Sleepy nutrition, less After 4-5 hours of measures helpful in implemented to
 Looks tired than body nursing interventions, promoting a balanced provide knowledge Patient was able to
 Weighs 90 requirements, the patient will be able nutrition of the patient. regarding proper show under-
lbs. related to lack to acquire basic nutrition. standings about
 152cm in of knowledge knowledge regarding importance of proper
height about postpartal her body’s nutritional and balanced
 Conscious needs. requirements. Document actual Patients may be nutrition.
 BMI is 18.2 The patient will be able height and weight. unaware of their
to: actual weight and BMI of the patient
height or weight loss. increased from 18.2
 Verbalize (underweight) to
understandings 18.8 (Normal
about the Obtain nutritional The patient’s weight)
importance of history; include family, perception of actual
proper nutrition. significant others, or intake may differ.
caregiver in
 Identify assessment.
interventions to
promote a Monitor or explore Many psychological,
balanced attitudes toward eating psychosocial, and
nutrition. and food. cultural factors:
determine the type,
 Demonstrate amount, and
techniques and appropriate-ness of
lifestyle food consumed.
changes to
promote proper
nutrition.
Long term Plan:
Encourage to take These nutrients are
After days the client foods, which is high in needed for good
will gain weight. protein, vitamins and tissue repair.
minerals.

Encourage to have an It is important to help

adequate supply of restore the peristaltic
roughage. action of the bowel.

Suggest liquid drinks Such supplemental

for supplemental can be used to
nutrition. increase calories and
protein without
interfering with
voluntary food intake.

Discourage beverages These may decrease

that are caffeinated or appetite and lead to
carbonated. early satiety.

Encourage exercise. Metabolism and

utilization of nutrients
are enhanced by
activity.

Discuss the importance Patients may not

of maintaining understand what is
adequate caloric intake involved in a
and the four basic food balanced diet. They
groups, as well as the are better able to ask
need for specific questions and seek
minerals and vitamins. assistance when they
know basic
information.
Collaborative:

Ascertain healthy
body weight for age Experts like a
and height. dietician can
determine nitrogen
balance as a
measure of the
nutritional status of
the patient.
Refer to a dietitian for A negative nitrogen
complete nutrition balance may mean
assessment and protein malnutrition.
methods for The dietician can
nutritional support. also determine the
patient’s daily
requirements of
specific nutrients to
promote sufficient
nutritional intake.
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Interventions
Objective Data: Activity Short term goal: Independent: Appropriate measures will Goal met. Patient
intolerance Render nursing be implemented to was able to tolerate
 Sleepy related to stress After 8 hours of measures helpful in increase energy level. activities within level
 Looks tired during labor nursing increasing energy of own ability as
 Generalized and birth. interventions, the level of the patient to evidenced by:
weakness patient will be able tolerate activities
noted to tolerate activities within level of own
With the following within level of own ability. Patient answered to
vital signs: ability. the question asked
and identified factors
 T-36.5 0C Assess sleep Multiple factors can aggravating fatigue.
 P-75bpm The patient will be patterns and note aggravate fatigue,
 R-20cpm able to: changes in thought including sleep
process. deprivation, emotional
 BP-110/70 Identify negative distress, side effects of Patient can sit and
mmHg factors affecting medication, and can do tooth brushing
performance. progression of disease by herself.
process.
 Adapt lifestyle to
increase energy Assess the patient’s This aids in defining what
level. level of mobility. the patient is capable of,
which is necessary before Patient moves slowly
 Verbalize settling realistic goal. and rest more often.
understanding of
potential loss of
ability in relation Patient eats the right
to existing Monitor patient’s Difficulties sleeping need kind and nutritious
condition. sleep pattern and to be addressed before foods.
amount of sleep activity progression can
 Develop an achieved over the be achieved.
activity and rest past few days.
pattern that Patient verbalizes
promotes optimal Provides for sense of what are her
independence Encourage patient to control and feeling of concerns on her
 and minimizes do whatever possible accomplishment. condition to the
fatigue. like self-care and sit nurse.
. in chair.

Long term goal: Shorter activity periods

After the nursing Suggest that the performed more slowly
intervention and in client perform and more frequent rest
5 days the client activities more slowly periods promote optimal
can exercise on her and for shorter times, performance and
own and will gain resting more often, achievement levels.
the energy to do and using more
some minor assistance as
activities or task at required.
home.
Necessary to meet energy
Encourage proper needs for activity.
nutritional intake.

Appropriate assistance
Plan time to be with ensures safety.
the patient, and listen
actively to the client’s
concern.

NURSING CARE PLAN

“Client with Activity intolerance”