Nursing Diagnosis: Fluid

Volume Deficit
Possible Etiologies:
(Related to)

Goals/ objectives:

Nursing Interventions

Nursing Actions

Uterine Atony
Lacerations
Retained placental
fragments
Disseminated
intravascular
coagulation
Subinvolution of
uterus

Defining characteristics:
(Evidenced by)



Blood loss more
than 500 ml
Heavy lochia flow
Increased
temperature due to
uterine infection
predisposing to
uterine atony
Elevation of pulse
rate indicating
hypovolemia
Sudden drop in
blood pressure
implying
hemorrhage
Pain in the perineal
sutures
Decreased uterine

Short term goal:



Rationale

Client will
maintain fluid
volume at a
functional level as
evidenced by
individually
adequate
haemoglobin,
hematocrit
laboratory results,
stable vital signs,
adequate urine
output, good
uterine
contractility, good
skin turgor and
capillary refill
after one week.


Long term goal:
Client will demonstrate
behaviours

Assess uterine
contraction and lochia
flow every 2 hours.
Assess vital signs and
note for peripheral
pulses.
Note client’s
physiologic response
to blood loss.
Keep accurate record
of subtotals of
solutions/ blood
products during
replacement therapy.
Maintain bed rest and
schedule activities to
provide undisturbed
rest periods.
Keep fluids within
reach of client.
Teach client perineal
self- care.
Encourage client to
do Kegel’s exercises
every 4 hours.
Administer fluids/
volume expanders as
indicated.
Replace blood
products as ordered
by the physician.
Administer


That is to note how
much blood loss the
client is
experiencing and to
prompt for
immediate
intervention.
Changes in BP and
pulse may be used
for rough estimate
of blood loss.
Postural
hypotension reflects
a decrease in
circulating volume.
Symptomatology
may be useful in
gauging severity of
bleeding episode.
Potential exists for
over transfusion of
fluids, especially
when volume
expanders are given
prior to blood
transfusion.
Activity may
predispose to further
bleeding.
To encourage fluid
intake
To prevent
development of
perineal infections.

Evaluation

Outcome Criteria:

Client’s pulse is
between 80 to 100
beats per min and
blood pressure is
110/60 mmHg,
lochia slows to
moderate amount of
flow with no large
clots, uterus is firm
and haemoglobin
level is above
11g/L.
Client verbalizes
understanding of the
causative factors
and purpose of
interventions and
medication;
participates in
procedures without
hesitations;
attentive and
monitors own vital
signs upon
assessment; and
follows restrictions
applied.


contractility
Drop in the
haemoglobin and
hematocrit
laboratory results
Decreased urine
output
Pallor, easy
fatigability, anxiety

methylergonovine as
prescribed by the
physician.
Monitor laboratory
studies (haemoglobin
and hematocrit,
creatinine/ BUN)
Assist in the
preparation for
surgery specifically
hysterectomy.

It helps improve the
blood supply in the
perineal area.
Fluid replacement
with isotonic
crystalloid solutions
depends on the
degree of
hypovolemia and
duration of bleeding.
Fresh whole blood,
platelets and fresh
frozen plasma are
usually given to
patients depending
on severity of blood
loss.
This drug helps in
the contraction of
the uterus.
Helps in monitoring
the effectiveness of
the therapy;
malfunction in the
kidneys may
indicate major
bleeding episodes.
It is the most
effective in halting
bleeding especially
an extremely atonic
uterus.

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