Cues Nursing Rationale Goal/ Expected Intervention Rationale Evaluation

Diagnosis Outcome
Subjective: Fluid volume Stress After 16 hours Independent: Independent: After 16 hours of
deficit related ↓ of nursing 1. Monitor vital signs, 1. Changes in vital signs nursing intervention,
“I felt weakness to excessive ↑ production of intervention, the compare with patient may be used for rough the patient was able
all over my body” blood loss as FSH & Estrogen patient will be normal or previous estimate of blood loose to:
as verbalized by ↓ readings. 2. Symptomatology may be
evidenced by able to:
the patient. Hyperexcitability 2. Note patient’s useless in gauging 1. Demonstrate
vaginal of uterine muscles individual severity or length of
bleeding, 1.Demonstrate improve fluid
↓ physiological bleeding episode.
Objective: pallor. Severation and improve fluid response to bleeding 3. Provide guidelines for balance as evidenced
damage to blood balance as such as weakness, fluid replacement. by stable vital signs,
 Pallor vessels evidence by restlessness and 4. Activity increases good skin turgor.
 1 day vaginal ↓ stable vital pallor. intrabdominal pressure
bleeding Detachment of the signs, good skin 3. Monitor intake and and can predispose to - Goal partially met-
 Unable to rise placenta turgor. output. further bleeding.
on bed ↓ 4. Maintain bed rest.
 Poor skin turgor Vaginal bleeding Schedule activities to Dependent:
 V/S ↓ provide undisturbed
T: 36.5˚C Blood loss rest periods. 1. Fluid replacement is
P: 80bpm dependent on the duration
R: 24cpm Dependent: of bleeding. Volume
BP: 100/70mmHg expanders may be infused
1. Blood transfusion. until type and cross –
2. Monitor Hb, Hct, match can be completed
RBC count. and blood transfusions
begun.
2. Aids in establishing blood
replacement needs and
monitoring the
effectiveness.
NURSING CARE PLAN