Jun 21st, 2015
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Monitor amount of bleeding by weighing all pads. ®To measure the amount of blood loss. • Frequently monitor vital signs.® Early recognition of possible adverse effects allows for prompt intervention.

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NURSING CARE PLAN ASSESSTMENT DATA(Subjective & Objective)NURSING DIAGNOSIS(problem and Etiology)GOALS AND OBJECTIVENURSING INTERVENTIONSAND RATIONALEEVALUATIONSubjective: " I'm still bleeding heavily after three days of giving birth." as verbalized by patient.Objective:- Restlessness- Confusion.- Irritability.- V/S taken as follows: T: 36.8 P: 100 R: 24 Bp: 100/70- 6 - 8 pads / day fully saturated perineal padIneffective tissue perfusion related to bleedingAfter 8 hours of nursing interventions, the patient will demonstrate adequate perfusion and stable vital signsIndependent:- Monitor amount of bleeding by weighing all pads. To measure the amount of blood loss.- Frequently monitor vital signs. Early recognition of possible adverse effects allows for prompt intervention.- Massage the uterus. To help expel clots of blood and it is also used to check the tone of the uterus and ensure that it is clamping down to prevent excessive bleeding.- Place the mother in Trendelenberg position. Encourages venous return to facilitate circulation, and prevent further bleeding.-Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercisesProvide diversional activities. Promotes relaxation and may enhance patient's coping abilities by refocusing attentionDependent:-Administer medication as indicated (e.g Pitocin, Methergine)To promote contraction and preve

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