CUES/ EVIDENCES NURSING DIAGNOSIS

OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

Subjective: Verbalized, Mga ikapito q nag-kalibanga itong gabiuna ug nagsukasuka pod ko.

Fluid and Electrolyte Imbalance related to active fluid loss due to frequent loose bowel movement and vomiting

At the end of my care, the patient will maintain fluid volume as evidenced by: Vital signs within normal range: BP=110-140/60-90 mmHg

Independent: Monitor the vital signs especially blood pressure To gather baseline data

Goal partially met as evidenced by: Vital signs within normal range: T=37 C, PR=72 bpm, regular, strong, RR= 21 cpm, regular, shallow in depth, without the use of accessory muscles, BP=120/80 Verbalization of discomfort and pain

Objective: Looks tired and worn out NPO temporarily according to chart Capillary refill 2 seconds Vital Signs: BP: 100/60 mmHg

Decreased frequency of bowel movement vomiting Verbalized decreased feeling of tiredness.

Monitor daily intake and output.

To ensure accurate picture of fluid status. Fluid replacement needs are based on correction of current deficits and ongoing losses. Promote comfort and prevent injury from dryness.

Provide frequent oral care as well as

Dry skin noted.

skin care with emollients Collaborative: Administer D5LR 1L to run at 44 gtts/min. Provide prompt circulatory improvement and replace fluids lost.

CUES/ EVIDENCES

NURSING DIAGNOSIS Risk for fluid volume deficit related to blood loss secondary to placental delivery

OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

Objective: NPO since 6am Mouth and lips are dry as noted. Skin snaps back within 2 seconds when pinched Gush of blood is present during the delivery of the newborn and placenta Blood loss of 350 cc Vital Signs: T=37 C, PR=72 bpm, regular, strong, RR= 21 cpm, regular, shallow in depth, without the use of accessory muscles, BP=120/80 mmHg Profuse sweating noted Laboratory Data: CBC

Within our care, the patient will be free from risk of dehydration as evidenced by: Vital signs within normal range: T=36.5 to 37.5C, PR=60 to 100 bpm, RR=16 to 20 cpm, BP=100-140/60-90 mmHg The patient will have moist lips Decreased sweating Firm fundus

Independent: Monitor vital signs and note for any significant changes

Goal met as evidenced by: Decreased BP, postural hypotension, and tachycardia are early signs of hypovolemia Provides information about the status of patients loss Indicators of dehydration and need for increased intake Boggy fundus indicates that there is absence of contraction thus risk for extensive bleeding To prevent dryness and Vital signs within normal range: T=37 C, PR=72 bpm, regular, strong, RR= 20 cpm, regular, shallow in depth, without the use of accessory muscles, BP=120/80 mmHg Lips are moist Decreased sweating Fundus is firm

Monitor intake and output

Inspect mucous membranes; evaluate skin turgor.

Monitor for the fundus for firmness after the delivery of placenta

Moisten the lips with cotton ball

Hemoglobin: 11.4 gm % Hematocrit: 32gm % WBC: 10, 300/cumm Neutrophil: 80 % Lymphocyte: 14 % Monocyte: 3 % Eosinophil: 3 % Basophil: 0 % Platelet count: 313,000 T/cumm IV fluid: D5LR 1L at 10-12 gtts/min

saturated with sterile water.

cracking of lips

CUES/ EVIDENCES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

Subjective: Verbalized, Sakit akong kinatawo!

Risk for maternal infection related to invasive procedures and traumatized tissues secondary to birthing process.

Within our care, our patient Independent will be free from signs and Note date and symptoms of infection as time of rupture of evidenced by: membranes Vital signs within normal range : T- 36.5 C-37.5 C PR- 60-100 bpm RR- 12-20 cpm BP- 100-140/60-90 mmHg No foul odor in the perineum Absence of purulent discharges in the perineum

Objective: Vital signs: T=37 C, PR=72 bpm, regular, strong, RR= 21 cpm, regular, shallow in depth, without the use of accessory muscles, BP=120/80 mmHg

Monitor vital signs and WBC count as indicated

Laboratory Data: CBC Hemoglobin: 11.4 gm % Hematocrit: 32gm % WBC: 10, 300/cumm Neutrophil: 80 % Lymphocyte: 14 %

Use surgical asepsis in preparing equipment Clean perineum with sterile water

Within 4 hours after Goal met as evidenced by: rupture of membranes, the Normal vital signs: client and fetus are at T=37 C, PR=72 increased risk for bpm, regular, strong, ascending tract RR= 21 cpm, infections and regular, shallow in possible sepsis depth, without the use of accessory muscles, BP=120/80 Increased mmHg temperature or pulse greater than 100 bpm No foul odor in the may indicate perineum infection. Normal No presence of protective purulent discharges leukocytosis with in the perineum WBC count as high as 25,000/mm3 must be differentiated from elevated WBC count caused by infection. Reduces risk of contamination

Reduces risk of contamination

 Monocyte: 3 % Eosinophil: 3 % Basophil: 0 % Platelet count: 313,000 T/cumm

and soap or surgical disinfectant just prior to delivery

Rupture of Membranes occur at 6am; received in the delivery room at 7:00 am. Dilatation of cervix measures 3 cm.

Immediately flush the fecal material when stool expulsion occurs.

Reduces risk of contamination

Median incision/episiotomy cut was done