Case Study 2
Case Study 2
Case Study 2
DEMOGRAPHIC DATA
• Patient name: H. A. N
• Address: Chukwani
• Age: 33 years
• occupation: Housewife
• Sex: Female
• Marital status: Married
• Hospital: Mnazi Mmoja
• Date of admission: march 04, 2016
Medical history
Treatment
Non-pharmacological treatment
• Resuscitation with intravenous fluid e.g. ringer
lactate
• Uterine massage every 15 minutes for the first
two hours
Pharmacological treatment
• Oxytocin 40 I.U via I.V in ringer lactate
Test results
• HB – 8.4mls
• Blood group - O+
• PMTCT - 2
Fluid volume deficit After 2 – 5 days I/: Advise patients to sleep with After 2 days the
related to uterine will be Prevented feet higher, while the body client’s body
from remained supine. fluid volume
atony as evidenced
dysfunctional R/: With feet higher will increase improved
by excessive
bleeding and the venous return, and allowing
vaginal blood loss.
improve fluid the blood to the brain and other
volume. organs.
I/: Monitor vital signs.
R/: Changes in vital signs when
bleeding occurs more intense.
I/: Monitor intake and output
every 15 minutes.
R/: Change the output is a sign of
impaired renal function.
NURSING EXPECTED INTERVENTION EVALUATIO
DIAGNOSIS OUTCOME N
Ineffective tissue After 2 – 3 days vital I/: Monitor vital signs every 5- After 2 days
perfusion related to signs and blood gases 10 minutes. patient’s vital
vaginal bleeding as will be within normal R/: Changes in tissue perfusion signs were at
evidenced by limits. causing changes in vital signs. normal range.
fluctuation of vital I/: Monitor blood gas levels
signs and pH
R/: Changes in blood gases and
pH levels are a sign of tissue
hypoxia
I/: Give oxygen therapy
R/: Oxygen transport is needed
to maximize circulation to
tissue.
NURSING EXPECTED INTERVENTION EVALUATION
DIAGNOSIS OUTCOME
Body weakness • Verbalize I/: Discuss with patient the need for The patient can
activity. Plan schedule with patient
related to altered increase in and identify activities that lead to perform some
body chemistry energy level. fatigue. activities
R/: Education may provide
(insufficient motivation to increase activity level
electrolytes) as • Display even though patient may feel too
weak initially.
evidenced by improved ability
inability to to participate I/: Increase patient participation in
ADLs as tolerated.
maintain usual in desired R/: It can increases confidence level,
routines. activities. self-esteem and tolerance.
Anxiety related to The client can I/: Assess the client's psychological Client said
response to the post- childbirth anxiety is
knowledge deficit verbalize bleeding. reduced.
regarding anxiety and said R/: Perceptions of client influence the
intensity of anxiety.
procedures, anxiety is
management and reduced or lost. I/: Treat the patient
calm, empathetic and supportive
disease condition attitude.
as evidenced by R/: Provide emotional support.
Sleeping pattern Falls asleep I/: Assess for new onset of depression: After 2 days the
disturbance without depressed mood state, statement of patient falls
related to acute difficulty hopelessness and poor appetite asleep without
pain as R/: It can help to understand which difficulty
evidenced by psychological therapy can help the patient
verbal report of
I/: Provide pain relief shortly before
difficult falling
bedtime
asleep.
R/: Help to keep the body not to suffer
from pain at that time.
Risk for To keep I/: Note the changes in vital signs. After 5 days the
infection patient free R/: Changes in vital signs (temperature) is patient was free
related to from indicative of infection. from infection
infection
excessive
I/: Note the signs of fatigue, chills, anorexia,
blood loss and uterine contractions were flabby and
and exposed pelvic pain.
placental R/: The signs are an indication of the
attachment occurrence of bacteremia, shock is not
site and detected.
lacerations.
I/: Consider the possibility of infection in
other places, such as respiratory infections,
mastitis and urinary tract.
R/: Infection elsewhere worsens the situation.