ASSESME

NT

NURSING
DIADNOS
IS

PLANNIN
G

INTERVENT
ION

RATIONAL
E

EVALUATI
ON

Subjective
Data:
dinudugo
ako ,
maraming
buo-buo na
lumabas
sakin As
verbalized
by the
patient

Fluid
volume,
deficient
related to
excessive
blood loss

After 8
hours of
nursing
interventio
n, the
patient
will
demonstra
te improve
fluid
balance as
evidence
by stable
v/s and
prompt
capillary
refill

Monitor
vital signs
Note
patients
individual
physiological
response to
bleeding
such as
changes in
restlessness,
weakness
and pallor.

To gather
data
May be
useful in
gauging
severity or
length of
bleeding

After
hours of
nursing
interventio
n the
patient was
able to
demonstrat
e improved
fluid
balance as
evidence
by stable
vital signs
and prompt
capillary
refill.

Objective:
Pale
looking
Restlessne
ss
Delayed
capillary
refill

Monitor
intake and
output (I&O)

Provide
guideline
for fluid
replaceme
nt.

With
bleeding
Vital signs

BP:
100/70
RR: 25
PR: 83
bpm
TEMP:
36.4

Maintain
bed rest
Schedule
activities
to provide
undisturbe
d rest
periods

Activity
increases
intraabdominal
pressure
and can
predispose
to further
bleeding

DEPENDEN
T:
Administe
r fluid as
indicated.

Fluid
replaceme
nt with
isotonic
solutions
depends
on the
degree of
bleeding
Promotes
hepatic
synthesis
of
coagulatio
n factors to

Administe
r Vit. K.

DRUG

THERAPEUTIC
ACTION

INDICATION

CONTRAINDICATIO
N

Carboprost
Tromethamine
IM

Stimulates the
myometrium of
the gravid uterus
to contract in a
manner that is
similar to the
contraction of
the uterus during
labor

Postpartum
hemorrhage due
to utirine atony
unresponsive to
conventional
methods.

With allergy to
prostaglandin
preparations: acute
PID: active cardiac,
hepatic, pulmunary
renal disease

Oxytocin

Stimulates the
uterus,
especially gravid
gravid the uterus
just before
parturition

To initiate or
improve
contraction to
achieve early
vaginal delivery

Use cautiously with

renal impairment.

Methylergonovin
e

It increase the
strength ,
duration and
frequency of
uterine

Treatment
postpartum
atony and
hemorrhage,
Routine

Use cautiously with

sepsis, hepatic or
renal imapirment.

oxytocin
in dextrose 5%-0
.9% sodium chlori
de intravenous

oxytocin
in dextrose 5%-0.
45% sodium chlorid
e intravenous

oxytocin
in dextrose 5%-0.
2% sodium chloride
intravenous