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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Postpartum Independent:
Subjective: Risk for hemorrhage is • After 8 hours • Monitor amount • To measure the • After 8 hours
ineffective tissue of nursing of bleeding by amount of blood of nursing
defined as a loss of
“Halos ilang perfusion related interventions weighing all loss. interventions,
linggo na ako to hemorrhage. blood in the , the patient pads. the patient
nakapanganak postpartum period will • Frequently • Early recognition was able to
pero malakas pa of more than 500 demonstrate monitor vital of possible demonstrate
rin ang mL. The average, adequate signs. adverse effects adequate
pagdurugo ko ” perfusion allows for prompt perfusion and
spontaneous
(I’m still bleeding and stable intervention. stable vital
heavily after weeks of vaginal birth will vital signs. signs.
giving birth) as typically have a 500
verbalized by mL blood loss. In • Massage the • To help expel
patient. cesarean births the uterus. clots of blood and
average blood loss it is also used to
Objective: check the tone of
rises to 800-1000
the uterus and
• Restlessness mL. There is a ensure that it is
greater risk of clamping down to
• Confusion. hemorrhage in the prevent excessive
first 24 hours after bleeding.
• Irritability.
the birth, called
• V/S taken as primary postpartum
follows: hemorrhage. A • Place the mother • Encourages
secondary in Trendelenberg venous return to
T: 36.8 hemorrhage occurs position. facilitate
P: 105 after the first 24 circulation, and
R: 24 prevent further
Bp: 100/70 hours of birth. In
bleeding.
the majority of
cases the cause of
hemorrhage is • Provide comfort • Promotes
uterine atony, measure like relaxation and
meaning that the back rubs, deep may enhance
breathing. patient’s coping
uterus is not
Instruct in abilities by
contracting enough relaxation or refocusing
to control the visualization attention.
bleeding at the exercises.
placental site. Provide
Other reasons for a diversional
activities.
hemorrhage would
include retained Collaborative:
placental fragments • Administer • To supply
(possibly including oxygen as adequate oxygen
a placenta accreta), indicated. to the fetus and
mother and
trauma of some
prevents further
form, like a cervical complication.
laceration, uterine
inversion or even
uterine rupture, and • Administer • To promote
clotting disorders medication as contraction and
indicated (e.g prevents further
Pitocin, bleeding.
Methergin)