Fluid Volume Deficit secondary to Post Partum Hemorrhage

Cues and Analysis Goals/Objectives Nursing Rationale Evaluation

Clues Intervention
Blood loss of Postpartum Short Term Goal: 1.Assess vital 1.Changes in BP
500mL hemorrhage is signs and note and pulse may
defined as any Long Term Goal: for peripheral be used for
Heavy Lochia loss of blood Client will pulses estimating
flow from the maintain fluid amount of blood
uterus more volume at a loss
Elevation of than 500 ml functional level
pulse rate within a 24 as evidenced by 2.Assess uterine 2.To note how
indicating hour period. It individually contraction and much blood loss
hypovolemia may be adequate lochia flow the client is
immediate or hemoglobin, every two hours experiencing
Sudden drop late occurring hematocrit and to prompt
in blood from the first laboratory for immediate
pressure 24 hours of results, stable intervention
implying delivery up to vital signs,
hemorrhage the remaining adequate urine 3. Note client’s 3.
days of the 6- output, good physiological Symptomatology
Soft uterus week uterine response to May be useful in
puerperium. contractility, blood loss gauging severity
Uterus not good skin turgor of bleeding
well and capillary episode
contracted refill after one
week 4. Keep 4. Potential
Decreased accurate record exists for over
urine output of the blood transfusion of
products during fluids
Drop in replacement
hemoglobin therapy
laboratory
results 5. Maintain bed 5.Activity may
rest and predispose to
schedule further bleeding
activities to
provide
undisturbed
rest periods

6.Keep fluids 6. To encourage

within reach of fluid intake
client
7.Administer 7.Fluid
fluids/volume replacement
expanders as with isotonic
indicated crystalloids
solutions
depends on the
degree of
hypovolemia
and duration of
bleeding

8.Replace blood 8.Fresh whole

products as blood, platelets
ordered by the and fresh frozen
physician plasma are
usually given to
patients
depending on
severity of blood
loss

9.Administer 9.This drug helps

oxytocin as in the
prescribed by contraction of
the physician the uterus

10.Monitor 10.Helps in
laboratory monitoring the
studies effectiveness of
(hemoglobin, the therapy;
hematocrit, malfunction in
creatinine/BUN) the kidneys may
indicate major
bleeding
episodes

11.Encourage 11.It helps

client to do improve the
Kegel’s blood supply in
exercises every the perineal
4 hours area

12.Teach client 12.To prevent

perineal self- development of
care perineal
infections
13.Assist in the 13.It is the most
preparation for effective in
surgery halting bleeding
specifically especially an
hysterectomy extremely atonic
uterus