dr ncp case study

8/11/2019 DR NCP Case Study

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NURSING CARE PLAN

ASSESSTMENT DATA(Subjective & Objective)

NURSINGDIAGNOSIS

(problem anEtiolo!")

GOA#S ANDO$%ETI'E

NURSING INTER'ENTIONSAND RATIONA#E

E'A#UATION

Subjective:

Im still bleeding heavily afterthree days of giving birth.as verbalized by patient.

Objective:

!estlessness

"onfusion.

Irritability.

#$S ta%en as follo&s:

': ().*

+: ,--

!: /

0p: ,--$1-

) 2 * pads $ day fully

saturated perineal pad

Ineffective tissue

perfusion related tobleeding

3fter * hours of nursing

interventions4 the patient&ill demonstrateade5uate perfusionand stable vital signs

Independent:

6onitor amount of bleeding by&eighing all pads. 7'o measurethe amount of blood loss. 8re5uently monitor vital signs.79arly recognition of possibleadverse effects allo&s for promptintervention. 6assage the uterus.7 'o helpepel clots of blood and it is alsoused to chec% the tone of theuterus and ensure that it isclamping do&n to prevent

ecessive bleeding. +lace the mother in'rendelenberg position.79ncourages venous return tofacilitate circulation4 and preventfurther bleeding.+rovide comfort measure li%ebac% rubs4 deep breathing.Instruct in relaation orvisualization eercises+rovide diversional activities.7+romotes relaation and may

enhance patients coping abilitiesby refocusing attention;ependent:3dminister medication as indicated


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6ethergine=7'o promote contractionbleeding."ollaborative:3dminister oygen as indicated.7'o supply ade5uate oygen to thefetus and mother and preventsfurther complication.

3dminister medication as indicated


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NURSING CARE PLAN


NURSINGDIAGNOSIS


GOA#S ANDO$%ETI'E


E'A#UATION

Subjective: >

Objective :

?@asal 8laring

?!estlessness

? O SaturationA 1* B

? delayed capillary refill Amore than ( sec.

?;ecreased Crine OutputA ,D ml$hr

?Increased Crine"oncentration A 0ro&nand hazy

Impaired gas echange

r$t altered blood flo& anddecreased surface areaof gas echange

3fter one hour of

nursing interventions4thept. Eill verbalizeunderstanding ofcausative factors andappropriate interventions

Independent:

?3ssessed vital signs 5 ,Fminutes7 +rovides baselinedata on the maternal blood loss?6aintained bed rest or chairrest &hen indicated. +rovidefre5uent rest periods anduninterrupted night timesleep.7Systemic rest ismandatory and importantthroughout all phases of dse. toreduce fatigue4and improvestrength.

?6onitored amt. and type ofbleeding.7+rovide objectiveevidence of bleeding.?+ositioned the mother onher left side. 7'o promoteplacental perfusion.?!estrict vaginaleamination7+revents tearingof placenta if placenta previa isthe cause of bleeding?6onitor fetal contractionsand fetal heart rate by eternal

monitor.73ssess &hether labor ispresent and fetal status andeternal system avoids cervicaltrauma.

3fter one hour of

nursinginterventions4thepatient &as able toverbalizeunderstanding ofcausative factors andappropriateinterventions.


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?6onitor positive attitudeabout fetal outcome.7Supportmother and child bonding .;ependent:? +rovide psychological support4activeG listening 5uestions orconcerns 7 to reduce aniety

? 9ncourage ade5uate rest andlimit activities to &ithin clienttolerance?+romote calm4 restfulenvironment 7 helps limit oygenneeds and consumptions"ollaborative:?3dminister oygen asindicated7 +rovides ade5uatefetal oygenation despite oflo&ered maternal circulatingvolume


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NURSING CARE PLAN


NURSINGDIAGNOSIS


GOA#S ANDO$%ETI'E

NURSING INTER'ENTIONSAND RATIONA#

E'A#UATION

Subjective : >

Objective:?0leeding 9pisodes ? ) very saturatedperineal pads changeevery hours

?8acial l Hrimace due of+ain or no complaint ofpain

?3bdomen soft$hard

&hen palpated

?6anifest 0ody Eea%ness

?o& 0+ A ,--$)- mmJg

?Increased J! A ,-F cpm

?;ecreased !! A,) bpm

?;ecreased CrineOutput A ,D ml$hr

?Increased Crine"oncentration A 0ro&nand hazy

8luid #olume ;eficient

r$t 3ctive 0lood ossSecondary to ;isrupted+lacental Implantation

3fter eight hours of

nursing interventionand medicalassistance4 +t. Eillehibit signs ofade5uate fluidbalance duringpregnancy

Inepenent

?3ssessed color4odor4consistency and amount ofvaginal bleedingK &eighpads7+rovides information aboutactive bleeding versus old blood4tissue loss and degree of blood loss?3ssessed hourly inta%e andoutput.7+rovides information aboutmaternal and fetal physiologiccompensation to blood loss?3ssessed baseline data andnote changes.7 3ssessment

provides information about possibleinfection?3ssessed abdomen fortenderness or rigidityG ifpresent4measure abdomen atumbilicus


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note for complaints of thirst orapprehension 73ssessmentprovides information about blood vol.4Os saturation and peripheralperfusion.?+rovide supplemental Oasordered via face mas% or nasal

cannula M ,-G,$min.7'o detectsigns of cerebral perfusionIntervention increases available O tosaturate decreased hemoglobin.?Initiate I# fluids as ordered


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? +rovide a diet high in iron:leanmeats4 dar% green leafy vegetables4eggs4 and &hole grains.7+roper dietand vitamins replace nutrient lossesfrom active bleeding to preventanemiaGiron is a necessarycomponent of hemoglobin

ollaborative?6onitor lab. Eor% as obtained:Jgb NJct4 !h and type4crossmatch for units !0"s4urinalysis4etc.7ab. Eor% provides informationabout degree of blood lossKpreparesfor possible transfusion.?Scheduled for ultrasound asordered.7Cltra sound provides infoabout the cause of bleeding?;etermine if +t. has any objectionsto blood transfusionsGinform

physician.7+t. may have religiousbeliefs related to accepting bloodproducts


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NURSING CARE PLAN


NURSINGDIAGNOSIS


GOA#S ANDO$%ETI'E

NURSINGINTER'ENTIONSAND RATIONA#E

E'A#UATION

Subjective :G >

Objective:

G9levated 0+4 +4!

GInsomnia

G!estlessness

G;ry mouth

G;ilated pupils

+atient complains of

apprehension4

nervousness4 tension

Inability to concentrate

Sha%ing

3 n i e t y

r $ ts t r e s sa n du n m e tn e e d s

3fter four hours of

nursing intervention thept. Eill ;emonstrate adecrease in aniety 3.9.0.reduction in presentingphysiological4 emotional4and$or cognitivemanifestations of anietyKand verbalization of reliefof aniety

;ependent:

?9stablished rapport.+rovide reassurance andcomfort.7 'o gain the trustand cooperation of the patient.?6onitored vital signs7Identify physical responsesassociated &ith both medicaland emotional conditions.?Observed the clients behavior.@ote any unusual activities.7'his can point to the clientslevel of aniety.

?!evie&ed results of diagnostictest. 7 'his may point tophysiological source of aniety?0e a&are of defensemechanisms that the pt.manifests. 7 It may interfere&ith ability to deal &ith problem.?!evie&ed coping s%ills that&as used in the past.7'odetermine those that might behelpful in the currentcircumstance.

?+rovided accurate informationabout placenta previa.7Jelpsclient to identify &hat is realitybased.

3fter four hours of

nursing interventionthe manifesteddecreased aniety390 reducedpresentingmanifestations ofaniety and the pt.Eas able to verbalizea relief from aniety


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?ist available resources orpersons4 including hotlines orcrisis managers. 7'o provideongoing and timely support.?!evie& strategies4such as roleplaying4 use of visualizations topractice anticipated

events7Cseful for beingprepared in dealing &ith anietyprovo%ing situation."ollaborative:? 3dminister antiGaniety drugs $sedatives4 as ordered 7 Jelpsto manage the pt.eperiencing aniety


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NURSING CARE PLAN


NURSINGDIAGNOSIS


GOA#S ANDO$%ETI'E


E'A#UATION

Subjective :G>

Objective:

GEea%ness or fatigue

G9ertional discomfort or

dyspnea

G3bnormal heart rate or

blood pressure in

response to activity

G9lectrocardiographic

changes reflecting

arrhythmia or ischemia

G +allor

3ctivity Intolerance r$t9nforced 0ed !est;uring +regnancySecondary to+ostpartum Jemorrhage

3fter t&o hours ofnursing intervention thept. Eill demonstrate adecrease in physiologicalsigns of intolerance 390normal range of pt.s vitalsigns.

Independent:?9valuate actual and perceivedlimitations of deficient in light ofunusual status.7 +rovidescomparative baseline and providesinformation about neededinterventions regarding 5uality of life?6onitor vital or cognitive signs4&atch for changes of bloodpressure4heart and respiratoryrateK note s%in pallor andcyanosis and the presence of

confusion.7 +rovides baseline datato detect the changes due tointolerance.?Increase eercise levelsgradually4 such as stopping torest for ( mins. during a ,-Gminute &al% or sitting do&n tobrush hair instead of standing.7+reserves conservation of energy;ependent:?+rovide positive atmosphere&hile ac%no&ledging difficulty of

the situation of the client.7 Hivesthe chance for the client to enhanceability to participate in activities.? 3ssist client in learning and

3fter t&o hours ofnursingintervention the+t.s vital signshave returned tonormal range andmanifesteddecreasedphysiologicalsigns of activityintolerance.


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demonstrate appropriate safetymeasures 7 to prevent injuries?3ssist &ith activities andprovide clients use ofassistance devices.7'o developindividually appropriate therapeuticregimens."ollaborative:?+romote comfort measuresand provide relief of pain7Sustains clients motivation

dr ncp case study

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