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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)
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.
Assess uterine
contraction and lochia
flow every 2 hours.
Assess vital signs and
note for peripheral
pulses.
Note clients
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 Kegels exercises
every 4 hours.
Administer fluids/
volume expanders as
indicated.
Replace blood
products as ordered
by the physician.
Administer
Evaluation
Outcome Criteria:
Clients 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.