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    Assessment Diagnosis Planning Implementation Rationale Evaluation

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    Margareth Dandan
    1) The client is experiencing severe vaginal bleeding and abdominal pain two days after giving birth. Her vital signs show signs of hypovolemic shock including a blood pressure of 100/70 mmHg and a heart rate of 122 bpm. 2) The diagnosis is inadequate tissue perfusion related to hypovolemia. The short term goal is to stabilize the client's vital signs within 3 hours. The long term goal is for the client to display hemodynamic stability after 3 days. 3) The plan is to establish rapport, monitor vital signs and labs, weigh blood loss, place the client in Trendelenburg position, maintain bed rest, provide health teaching, administer oxygen and IV fluids as

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    Assessment Diagnosis Planning Implementation Rationale Evaluation

    Uploaded by

    Margareth Dandan
    31 views2 pages
    1) The client is experiencing severe vaginal bleeding and abdominal pain two days after giving birth. Her vital signs show signs of hypovolemic shock including a blood pressure of 100/70 mmHg and a heart rate of 122 bpm. 2) The diagnosis is inadequate tissue perfusion related to hypovolemia. The short term goal is to stabilize the client's vital signs within 3 hours. The long term goal is for the client to display hemodynamic stability after 3 days. 3) The plan is to establish rapport, monitor vital signs and labs, weigh blood loss, place the client in Trendelenburg position, maintain bed rest, provide health teaching, administer oxygen and IV fluids as

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    1) The client is experiencing severe vaginal bleeding and abdominal pain two days after giving birth. Her vital signs show signs of hypovolemic shock including a blood pressure of 100/70 mmHg and a heart rate of 122 bpm. 2) The diagnosis is inadequate tissue perfusion related to hypovolemia. The short term goal is to stabilize the client's vital signs within 3 hours. The long term goal is for the client to display hemodynamic stability after 3 days. 3) The plan is to establish rapport, monitor vital signs and labs, weigh blood loss, place the client in Trendelenburg position, maintain bed rest, provide health teaching, administer oxygen and IV fluids as

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    31 views2 pages

    Assessment Diagnosis Planning Implementation Rationale Evaluation

    Uploaded by

    Margareth Dandan
    1) The client is experiencing severe vaginal bleeding and abdominal pain two days after giving birth. Her vital signs show signs of hypovolemic shock including a blood pressure of 100/70 mmHg and a heart rate of 122 bpm. 2) The diagnosis is inadequate tissue perfusion related to hypovolemia. The short term goal is to stabilize the client's vital signs within 3 hours. The long term goal is for the client to display hemodynamic stability after 3 days. 3) The plan is to establish rapport, monitor vital signs and labs, weigh blood loss, place the client in Trendelenburg position, maintain bed rest, provide health teaching, administer oxygen and IV fluids as

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    DANDAN, Margareth Joy A.

    BSN 2B3

    Assessment Diagnosis Planning Implementation Rationale Evaluation


    Subjective Data: Inadequate tissue Short term goal: Independent: Short term goal:
    “Two days na po perfusion related to After 3 hours of 1. Establish rapport. 1. To gain the client’s After 3 hours of
    after kong manganak hypovolemia as nursing intervention trust and nursing intervention
    and bigla po akong evidenced by the client’s vital signs cooperation. the client’s vital signs
    nakaramdam ngayon severe vaginal will be 110/80 2. Monitor vital signs 2. To assess for is 110/80 mmHg.
    ng sobrang pananakit bleeding, severe mmHg. and labs for arterial hypovolemic shock
    po ng aking tiyan and abdominal pain, blood gases, and and decreased tissue Long term goal:
    meron din po akong paleness of the Long term goal: hematocrit and perfusion. After 3 days of
    malakas na skin, pallor, weak, After 3 days of hemoglobin levels. nursing intervention
    pagdurugo.” As changes in vital nursing intervention 3. Monitor the amount 3. To measure the the client displays
    verbalized by the signs, and changes the client will display of bleeding by amount of blood loss. hemodynamic
    client. of level of hemodynamic weighing all the pads stability as evidenced
    consciousness. stability as evidenced that are used. by stabled vital signs,
    Objective Data: by stable vital signs 4. Place the client in 4. To encourage venous arterial blood gases
     Severe within normal range, Trendelenburg return to facilitate labs showed no signs
    vaginal appropriate blood position. circulation and of acidosis,
    bleeding. gases, adequate prevent further hemoglobin and
     Severe hemoglobin and bleeding. hematocrit were
    abdominal hematocrit level. 5. Maintain bed rest and 5. Activity may within normal range.
    pain. schedule activities to predispose to further
     Weak provide undisturbed bleeding.
    palpable rest periods.
    pulses. 6. Keep fluid within 6. To encourage fluid
     BP: 100/70 reach of client. intake.
    mmHg. 7. Health teaching 7. To prevent the
     HR: 122 bpm. regarding perineal development of
     RR: 32 bmp. self- care. perineal infections.
     Extremely
    pale. Collaborative:
     Pallor and 1. Administer 2-3 L 1. To keep SpO2 >95%.
    weak. oxygen via nasal
     Drowsiness. cannula.
    2. Administer fluids, 2. To rapidly sustain
    electrolytes, colloids, circulating volume,
    blood products, as electrolyte balance,
    indicated. and prevent shock
    state.

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