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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for Postpartum After 8 hours Independent: • After 8 hours


“Halos ilang ineffective tissue hemorrhage is of nursing • Monitor amount • To measure of nursing
linggo na ako perfusion defined as a interventions of bleeding by the interventions,
nakapanganak related loss of , the patient weighing all amount of blood the patient
pero malakas pa to hemorrhage blood in the will pads. loss. was able to
rin ang postpartum demonstrate demonstrate
pagdurugo ko ” period adequate • Frequently • Early adequate
(I’m still bleeding of more than perfusion monitor vital recognition perfusion and
heavily after weeks 500 and stable stable vital
signs. of possible
of mL. The vital signs. adverse effects signs.
giving birth) as
average, allows for
verbalized by spontaneous
patient. prompt
vaginal birth will intervention.
Objective: typically have a
• Restlessness • Massage the • To help expel
500 clots of blood
• Confusion. mL blood loss. uterus.
and
• Irritability. In it is also used to
cesarean births check the tone
the of
average blood the uterus and
loss ensure that it is
rises to 800- clamping down
1000 to
mL. There is a prevent
greater risk of excessive
hemorrhage in bleeding.
the • Place the • Encourages
first 24 hours mother venous return to
after in Trendelenberg facilitate
the birth, called position. circulation, and
primary
prevent further
postpartum
bleeding.
hemorrhage. A • Provide comfort • Promotes
secondary measure like relaxation and
hemorrhage back rubs, deep may enhance
occurs breathing. patient’s coping
after the first 24 Instruct in abilities by
hours of birth. In relaxation or refocusing
the majority of visualization attention.
cases the cause exercises.
of Provide
hemorrhage is diversional
uterine atony, activities.
meaning that the
uterus is not
contracting
enough Collaborative:
to control the • Administer
bleeding at the oxygen as • To supply
placental site. adequate
indicated.
Other reasons oxygen
• Administer
for a to the fetus and
medication as
hemorrhage mother and
indicated (e.g
would prevents further
Pitocin,
include retained complication.
Methergi
placental • To promote
fragments contraction and
(possibly prevents further
including bleeding.
a placenta
accreta),
trauma of some
form, like a
cervical
laceration,
uterine
inversion or
even
uterine rupture,
and
clotting
disorders