ASSESSMENT NURSING SCIENTIFIC GOALS/ OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS RATIONALE INTERVENTIONS

Objective: Fluid Volume Atony refers to lack Short Term: Independent: Short term:
 estimated Deficit related of muscle tone that After 3 hours of nursing  Assess vital  These changes After 3 hours of
blood loss to Uterine results in failure of intervention, the patient signs, noting the in vital signs are nursing
of 900ml Atony the uterine muscle will be able to verbalize blood pressure associated with intervention, the
 BP 120/70 fibers to contract understanding of and pulse rate. fluid volume patient was able to
 RR 29 firmly around blood causative factors and loss and/ or verbalized the
 Temp vessels when the purpose of individual hypovolemia. causative factors
38.5C placenta separates. therapeutic interventions and purpose of
 Uterus With uterine atony, and medication and will individual
slightly the relaxed muscles maintain fluid volume at a  Change the  To reduce therapeutic
boggy with allow rapid bleeding functional level as position pressure on interventions and
vaginal from the endometrial evidenced by individually frequently, turn fragile skin and medication and was
bleeding arteries at the adequate hemoglobin, side to side tissues. able to maintain
 soft uterus placenta site. hematocrit laboratory every 2 hours if fluid volume at a
(not well results, stable vital signs, necessary. functional level as
contracted) adequate urine output, evidenced by
 Sources: good uterine contractility,  Discuss factors  Early individually
Foundations of good skin turgor and related to identification of adequate
Maternal-Newborn capillary refill. occurrence of risk factors can hemoglobin,
and Women’s health deficit as decrease hematocrit
Nursing, 6th edition, Long Term: individually occurrence and laboratory results,
Murray and After 2 days of nursing appropriate. severity of stable vital signs,
McKinney interventions, the patient complications adequate urine
will be able to associated with output, good
demonstrate behaviors to hypovolemia. uterine contractility,
monitor and correct good skin turgor
deficit, as indicated. and capillary refill.
 Measure the  To note how
amount of blood blood loss Long term:
loss. affects the After 2 days of
patient’s fluid nursing
volume status. interventions, the
patient was able to
 Explain the drug  To inform the demonstrate
which is ordered patient for the behaviors to
to the patient possible monitor and correct
and how it takes therapeutic deficit, as indicated.
its function. effects of the
drug.

 Instruct the  To prevent the

patient to recurrence of
maintain at bed vaginal
rest. bleeding
associated with
frequent
motion/
movements.

 Provide  To replace and

Intravenous (IV) conserve blood
fluids as ordered volume contrary
by the to the blood
physician. loss caused by
vaginal
bleeding.