Fluid defect and more, subjectiveNCP.docx

med surgical hospital Nursing NCP about maternal and child nursing and possible complication related to blood loss after birth of the baby and management with dependent and independent nursing intervention and nursing diagnosis and action and rationale

1. Assessment Nursing Diagnosis Desired Outcomes Nursing Interventions Rationale Evaluation
Objective
- Hemoglob
in of
81.0mg/dl





Deficit fluid
volume related to
excessive blood
loss after birth
based on
Complete blood
count
After 12 hours of patient
interactiom, patient
willbe able to
demonstrate
improvement in the
fluid balance.
Demonstrate proper
positioning with legs
elevated
Assess the fundal by
massaging,
administration of
medications, and
assesing her condition
1. Assess and record
the type, amount,
and site of the
bleeding; Count and
weight perineal
pads and if possible
save blood clots to
be evaluated by the
physician.
2. Assess the location
of the uterus and
degree of the
contractility of the
uterus.
3. Provide fundal
massage using one
hand and place the
second hand above
the symphisis pubis.
4. Position client flat
on bed with legs
elevated.
5. Administer fresh
whole blood or
other blood
products
1. The amount of
blood loss and
presence of
blood clots will
help to
determine the
appropriate
replacement
need of the
patient
2. Assessing the
degree of
contractility of
the uterus help
on the
measurement of
the blooc the
possible blood
loss
3. Fundal
massaging can
stimulate
contraction of
the uterus and
placing the other
hand abovr the
Goal met:
After 12 hours of
patient
interaction, the
patient was able
to demonstrate
improvement in
the fluid balance
as evidenced by
A good capillary
refill of <2 secs
Maintained a BP
of at least
100/60mmhg
Has a good skin
turgor.

2. 6. Administer
oxytocin and
methylergonovine
as ordered
7. Monitor laboratory
values specially
hemoglobin,
hematocrit, and
platelet count.
symphisis pubis
can prevent
uterine inversion
during massge
4. The position
increase venous
return, making
sure a greater
availability of
blood to the
brain and other
vital organs.
Bleeding may be
decreased with
the bed rest.
5. This is important
for rapid or
multiple infusion
of the fluids or
blood products
to increase
circulating
volume and
enchance
clothing.
6. Increases
contractility of
the boggy uterus,
and

3. myometrium,
close off exposed
venous sinuses,
and stops
hemorrhage in
the presence of
atony.
7. Monitoring
laboratory values
.

4. Assessment Nursing Diagnosis Desired Outcomes Nursing Interventions Rationale Evaluation
Objective:
- Fundus
boggy and
above the
level of
umbilicus
- Bp: 90/60
- RR: 60


Fluid volume
deficit related to
Active fluid
volume loss as
evidenced
by boggy fundus
above the level of
the umbilicus, and
blood clots
Short-Term:
After 1-hour of
nursing intervention,
the patient will be
able to;. Identify risk
factors and
appropriate
interventions.
Maintain a bp of at
least 100/60mmHg.
Maintain a pr
between 70-
90 bpm
Long-Term:
After 2 days of
nursing intervention,
the
Independent:
Place the
patient in a
Trendelenburg
position.
Compare
current fluid
intake to fluid
goal. Monitor
intake and
output
balance.
Assess skin
and oral
mucus
membranes
Independent:
Encourages
various
return to
facilitate
circulation,
and prevent
further
bleeding.
To ensure an
accurate
picture of
fluid status
For signs of
dehydration
such as dry
skin and
mucus
membranes,
poor skin
turgor,
delayed
capillary
refill, or flat
neck veins
To increase

Short-Term:
After 1-hour of
nursing
intervention,
the patient was
able
to;
Identify risk
factors and
appropriate
interventions
.
Maintain a
bp of at least
100/60mm

5. patient will be able to;
Maintain
fluid volume at a
functional level.


Offer a
variety of
fluids and
water-rich
foods, and
make them
available
throughout the
day.
Dependent:
Administer
oxytocin as
ordered
Collaborative:
Consult
dietician as
needed
the client’s
daily fluid
intake.
Dependent:
In the
presence of
atony,
increases
contractility
of the boggy
uterus and
myometrium
, closes
exposed
venous
sinuses, and
stops
hemorrhage.
Hg.
Maintain a pr
between 70-
90 bpm
Long-Term:
After 2 days of
nursing
intervention, the
patient was able
to;
Maintain
fluid volume
at a
functional
level.
Demonstrate
behaviors or
lifestyle

6. changes to
prevent
development
of fluid
volume
deficit
GOAL MET

8. Assessment Nursing Diagnosis Desired Outcomes Nursing Interventions Rationale Evaluation
Objective:
CBC
Hemoglobin: 81.0

Subjective:
The patient
Verbalize “ maluya
ha lawas permi “
Risk for Infection
related to
decrease in
hemoglobin
Short-Term
After 1-hour of
nursing intervention, the
patient will be able
to: Verbalize
understanding of
individual causative or
risk factor(s)
Identify interventions
to prevent or reduce risk
of infection
Long-Term
After 2-days of
nursing intervention, the
patient will be able
to;
Independent:
Assess signs
and symptoms of infection
especially temperature.
Note risk factors for
occurrence of infection.
Encourage early
ambulation,deep breathing,
and position changes
Dependent:
Independent:
Reflective of
inflammatory
process/ infection
requiring
evaluation and
treatment
To evaluate
presence/characte
r of the infection
For mobilization of
respiratory
secretions and
prevention of
aspiration/respirat
ory infectio

Short-Term
After 1-hour of
nursing
intervention, the
patient was able
to:
Verbalize
understandin
g of
individual
causative or
risk factor(s)
Identify
interventions
to prevent or

9. Demonstrate
techniques and lifestyle
changes to promote safe
environment.

reduce risk
of infection
Long-Term
After 2-days of
nursing
intervention, the
patient was able
to;
Demonstrate
techniques and
lifestyle changes
to
promote safe
environment
GOAL MET