Uterine Atony, Nursing care plan PDF

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Summary

o Pathophysiologyo Describe the importance of diagnostic and laboratory test in the given scenario.There are no specific diagnostic or laboratory tests that are mentioned in the case but in reality, diagnostic procedure such as physical examination (abdomen and vagina) is done immediately upon deliv...

Description

o Pathophysiology o Describe the importance of diagnostic and laboratory test in the given scenario. There are no specific diagnostic or laboratory tests that are mentioned in the case but in reality, diagnostic procedure s (abdomen and vagina) is done immediately upon delivery to access the uterine tone. The examination of an individual w that seems enlarged and soft, commonly referred to as “boggy” and will also typically contain a significant amount of b bleeding through the vaginal channel. -A bedside obstetric ultrasound can also be performed to confirm the diagnosis. The ultrasound imaging of the uterus m stripe inside the uterine cavity, which usually corresponds to the remaining parts of the placenta that were not complet -Blood tests such as Hemoglobin or Hematocrit are also done to monitor status and volume of blood loss since a patient post-partum hemorrhage.

o Nursing care plan (Priority and potential Nursing Diagnosis) Priority: Fluid volume deficit related to Active fluid volume loss as evidenced by boggy fundus above the le clots

ASSESSMENT The nurse on duty found the fundus is boggy and above the level of the umbilicus, her BP reveals 90/60 and PR 60 with bounding pulse.

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Fluid volume deficit related to Active fluid volume loss as evidenced by boggy fundus above the level of the umbilicus, and blood clots

Short-Term: After 1-hour of nursing intervention, the patient will be able to;

Independent:

Independent:

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Identify risk factors and appropriate interventions . Maintain a bp of at least 100/60mm Hg.

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Place the patient in a Trendelenburg position.

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Encourag various return facilitate circulation and prev further bleeding.

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Compare current fluid intake to fluid goal. Monitor intake and output balance. Assess skin and oral mucus membranes

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To ensure accurate picture fluid statu

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For signs dehydratio such as skin mucus membrane poor s turgor, delayed capillary refill, or neck vein To incre the clie daily f intake.

Maintain a pr between 7090 bpm 

Long-Term: After 2 days of nursing intervention, the patient will be able to;

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Maintain fluid volume at a functional level. Demonstrate behaviors or lifestyle changes to prevent development of fluid l

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Offer a variety of fluids and water-rich foods, and k h

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Collaborative:

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Consult dietician as needed.

Collaborative:

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To deve dietary p and iden foods to limited omitted.

(pa-check na lang netong ncp sa priority at Risk ate Daneya hehe, baka may mali or kulang) < Potential: Risk for Infection related to decrease in hemoglobin (on the spot kami nag isip ng diagnosis huh ASSESSMENT

DIAGNOSIS PLANNING INTERVENTION RATIONALE Independent: Independent: Risk for Infection Short-Term  Assess signs  Reflective related to After 1-hour of and inflammato decrease in nursing symptoms of process/ intervention, the hemoglobin infection requiring patient will be able especially evaluation to: temperature. treatment  Verbalize understandin g of  Note risk  To e individual factors for presence/c causative or occurrence r of the infe risk factor(s) of infection.  Identify interventions  Encourage  For mobiliz to prevent or early respiratory reduce risk ambulation, secretions of infection deep prevention breathing, aspiration/ and position ory infectio Long-Term changes After 2-days of Dependent: nursing intervention, the patient will be able to;  Demonstrate techniques and lifestyle changes to promote safe environment...