NCP FOR DELIVERY ROOM

RISK FOR DEFICIENT FLUID VOLUME AFTER PREGNANCY

 ASSESSMENT NURSING DIAGNOSIS BACKGROUND GOALS AND NURSING RATIONALE EVALUATION
KNOWLEDGE OUTCOMES INTERVENTION
/ANALYSIS
Subjective Cues: Deficient Fluid Volume Deficient Fluid After 24 hours of 1. Assess vital signs and 1. Decreased fluid After the nursing
“Nakakaramdam po ako ng related to excessive blood Volume/Postpartum nursing intervention monitor for signs of volume will cause intervention has been
hilo” as verbalized by the loss and disseminated Hemorrhage is defined the patient will be shock. blood pressure to given, the goal is me
patient. intravascular coagulation, as any loss of blood able to: 2. Monitor blood loss drop and patient 1. Maternal
and uterine atony after from the uterus more 1. Prevented  Site will go into shock. signs stab
Objective Cues: pregnancy as evidenced than 500mL within a from  Type 2. Amount of blood 2. Bleeding
 Pallor by blood loss more than 24-hour period. It may dysfuncti  Amount – loss and presence diminishe
 Soft Uterus 500 mL, heavy lochia be immediate or late onal should be nor of blood clots can stable.
 Uterus not well flow, increased occurring from the first bleeding. more than 1 help determine 3. Assessme
contracted temperature due to 24 hours of delivery up 2. Improve perineal pad treatment. findings
 Blood loss of 500 mL per hour
infection predisposing to to the remaining days of fluid 3. If bleeding is due within no
 Uncontrolled
uterine atony, elevation of the 6-week puerperium, volume.  Presence of to vaginal limits
Bleeding
pulse rate indicating clots hematoma, rest
 Heavy Lochia flow
 Drop in hemoglobin
hypovolemia, decreased 3. Assess for vaginal and application of
laboratory results urine and sudden drop in hematoma an ice pack may be
Low Hemoglobin: blood pressure implying 4. Monitor intake and sufficient
10.0 g/dl (normal hemorrhage. output for 30mL – 50 treatment
range 12.0 g/dl) m/hr urine output; 4. Decreased urine
 Uncontrolled may require output may be
Bleeding indwelling catheter assign of
V/S insertion for accurate hematomas that
 Blood Pressure 90/70 measurement put pressure on the
mm/ hg 5. Monitor lab values to urethra, or may be
 Temperature: 35.4℃ determine need for a late sign of
 PR: 140 BPM transfusions ir signs of hypovolemic
 RR: 20 complications shock
 6. Watch hematocrit and
5. Administer IV clotting levels to know
fluids, medications if blood transfusion is
and blood necessary and for
products as signs and severity of
necessary DIC.
 Oxytocin 7. Fluid replacement may
 Antibiotics be necessary and
 Analgesics depending on amount
6. Perform uterine of blood lost and
massage to hematocrit level, a
stimulate blood transfusion may
contractions be required. Oxytocin
following delivery is sometimes given to
7. Monitor and initiate contractions
manage pain that will help stop
8. Place patient on bleeding.
bed rest with legs 8. Begin fundal massage
elevated and educate patient on
9. Prepare patient how to massage
for surgery if abdomen to stimulate
indicates; remain contractions. These
on NPO status contractions may help
stop bleeding
9. Continued, unrelieved
pain may be due to
hematomas or
lacerations within the
vagina
10. Rest and elevation of
legs helps venous
return and slows
bleeding.
11. If bleeding can’t
be managed
otherwise, surgery
may be required.