Nursing Diagnosis: Fluid Goals/ objectives: Nursing Interventions Rationale Evaluation

Volume Deficit

Possible Etiologies: Nursing Actions  That is to note how Outcome Criteria:

(Related to) Short term goal: much blood loss the
 Assess uterine client is  Client’s pulse is
 Uterine Atony  Client will contraction and lochia experiencing and to between 80 to 100
 Lacerations maintain fluid flow every 2 hours. prompt for beats per min and
 Retained placental volume at a  Assess vital signs and immediate blood pressure is
fragments functional level as note for peripheral intervention. 110/60 mmHg,
 Disseminated evidenced by pulses.  Changes in BP and lochia slows to
intravascular individually  Note client’s pulse may be used moderate amount of
coagulation adequate physiologic response for rough estimate flow with no large
 Subinvolution of haemoglobin, to blood loss. of blood loss. clots, uterus is firm
uterus hematocrit  Keep accurate record Postural and haemoglobin
laboratory results, of subtotals of hypotension reflects level is above
Defining characteristics: stable vital signs, solutions/ blood a decrease in 11g/L.
(Evidenced by) adequate urine products during circulating volume.  Client verbalizes
output, good replacement therapy.  Symptomatology understanding of the
 Blood loss more uterine  Maintain bed rest and may be useful in causative factors
than 500 ml contractility, good schedule activities to gauging severity of and purpose of
 Heavy lochia flow skin turgor and provide undisturbed bleeding episode. interventions and
 Increased capillary refill rest periods.  Potential exists for medication;
temperature due to after one week.  Keep fluids within over transfusion of participates in
uterine infection reach of client. fluids, especially procedures without
predisposing to  Teach client perineal when volume hesitations;
uterine atony Long term goal: self- care. expanders are given attentive and
 Elevation of pulse Client will demonstrate  Encourage client to prior to blood monitors own vital
rate indicating behaviours do Kegel’s exercises transfusion. signs upon
hypovolemia every 4 hours.  Activity may assessment; and
 Sudden drop in  Administer fluids/ predispose to further follows restrictions
blood pressure volume expanders as bleeding. applied.
implying indicated.  To encourage fluid
hemorrhage  Replace blood intake
 Pain in the perineal products as ordered  To prevent
sutures by the physician. development of
 Decreased uterine  Administer perineal infections.
 contractility methylergonovine as  It helps improve the
 Drop in the prescribed by the blood supply in the
haemoglobin and physician. perineal area.
hematocrit  Monitor laboratory  Fluid replacement
laboratory results studies (haemoglobin with isotonic
 Decreased urine and hematocrit, crystalloid solutions
output creatinine/ BUN) depends on the
 Pallor, easy  Assist in the degree of
fatigability, anxiety preparation for hypovolemia and
surgery specifically duration of bleeding.
hysterectomy.  Fresh whole blood,
platelets and fresh
frozen plasma are
usually given to
patients depending
on severity of blood
loss.
 This drug helps in
the contraction of
the uterus.
 Helps in monitoring
the effectiveness of
the therapy;
malfunction in the
kidneys may
indicate major
bleeding episodes.
 It is the most
effective in halting
bleeding especially
an extremely atonic
uterus.