Casas, Jannen A.

A4 - Luage

COLLEGE OF NURSING
Silliman University
Dumaguete City

NURSING CARE PLAN

CARE OF WOMAN DURING THIRD STAGE OF LABOR
CUES/EVIDENCES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective data: Risk for Fluid Volume Within our 7 hours After our 7 hours of care, the
Deficit related to of care, the mother mother was free from fluid
Verbalized “wala ko
excessive blood loss shall be free from volume deficit as evidenced
nakainom ug tubig
sukad ganihang fluid volume deficit Independent: by:
kadlawon” as evidenced by: GOALS MET:
1. Monitor vital signs To obtain baseline
Objective Data: • Maintain vital especially blood data. Oxytocin
 Maintained vital sign
sign at normal range pressure after administration is
Excessive diaphoresis at normal range
placenta delivery contraindicated if o T: 36.10C –
noted o T: 36.10C – blood pressure is 37.20C
Flushed face noted 37.20C 140/90 mmHg o P:60-100 bpm
o P:60-100 o R:12-20 cpm
Placenta delivered at:
bpm o BP (90-120/60-
11:37 am
80 mmHg)
About 500 ml of gushed o R:12-20 cpm  No signs of face
blood is observed flushing
o BP (90-  Manifested no signs of
during the newborn and
placenta delivery 120/60-80 mmHg) dehydration
2. Monitor laboratory To obtain patient data  Maintained sufficient
Perineal laceration • Maintain
results (serum that may affect fluid volume
present sufficient fluid
electrolytes, bleeding and clotting
Casas, Jannen A. A4 - Luage

Vital Signs: volume and Hemoglobin&Hemato actions & to preserve

electrolyte balance crit) kidney function.
 T= 36.9 °C
 P= 80 bpm To obtain monitoring
 R= 20 cpm 3. Evaluate patient’s
data and determine
 BP= 120/90 • Manifest no hydration status: alterations in fluid
mmhg sign of dehydration, Assess mucous volume and
show good skin membranes, skin electrolyte imbalance.
turgor, moist turgor, and capillary
mucuos membrane refill.
and promt capillary
refill within 3
seconds 4. Inspect maternal and Helps detect
fetal surfaces of abnormalities that
placenta may have on impact
on maternal and
Dependent: newborn.
5. Assist on Intravenous Aids on correction
Therapy as ordered by the and prevention of
obstetrician. Fluid Volume Deficit

6. Administration of oxytoxic Stimulates regular

drug as ordered by the uterine contraction
obstetrician. thus preventing
hemorrhage.