NURSING CARE PLAN 1: (paki-specify nalang dito yung nursing diagnosis)

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
NURSING CARE PLAN 2: Risk for profuse vaginal bleeding

ASSESSMEN NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EXPECTED

T DIAGNOSI EXPLANATION S INTERVENTIONS OUTCOME
S
Risk for bleeding After 3 hours 1. Routinely 1. Monitoring the vital signs After 3 hours
Subjective: Ø Risk for may arise in any of nursing monitor the is a helpful intervention of nursing
profuse condition that interventions client’s vital to establish baseline interventions
Objective: vaginal disturbs the , patient will: signs. data and to further , patient has:
bleeding “close circuit” assess and watch our for 1. Established
Vital signs: 1. Establish
2. Advise
integrity of the patient and signs of bleeding. safety
 Temp: 37C circulatory safety measures in
family 2. Early evaluation and
 RR: 18 system. Examples measures in order for her
order for her members treatment of bleeding by
bpm of these to decrease
to decrease about signs a health care provider
 PR: 81 conditions bleeding.
bleeding. of bleeding reduce the risk for
bpm include traumatic 2. Been able
that need complications from blood
 BP: 120/80 injury, major loss. to realize the
2. Be able to be
organ surgery, 3. The lochia is the actual signs
to realize the reported to
and the many actual signs of bleeding
a physiological postpartum
inflammatory and of bleeding which require
Patient may healthcare uterine discharge
manifest the ulcerative which to be
provider. consisting mainly of
ff: disorders of the require to be reported
3. Assess the blood and necrotic tissue
 Increase in gastrointestinal reported immediately
classificatio that occur during the first
body system like immediately to a health
n of lochia. 4-6 weeks after delivery
temperatur inflammatory to a health care
of the baby. Assessing
e bowel disease care Give proper provider.
provider. such will further
and peptic ulcer After 2 days
 Hypotensio perineal care to determine if hemorrhage
disease. Drugs the patient. of nursing
n will occur.
may also be the After 2 days interventions
 Tachycardi of nursing
reason why a Proper perineal care could be a , patient has
a interventions
patient’s bone step to reduce the risk for no longer
 Low marrow function , patient will experienced
bleeding because of the
hematocrit is suppressed no longer hygienic advantages it can give. excessive
which increases experience vaginal
excessive
the patient’s risk bleeding.
for bleeding. vaginal
These drugs bleeding.
include
anticoagulants,
nonsteroidal anti-
inflammatory
drugs (NSAIDs),
and cancer
chemotherapy
agents. Bleeding
is the primary
complication of
anticoagulant
therapy and is a
risk of all
anticoagulants
even when
maintained
within usual
therapeutic
ranges. Herbal
remedies may be
connected to
bleeding
problems
through direct
effect on clotting
factors or
interactions with
anticoagulants.
NURSING CARE PLAN 3: (paki-specify nalang dito yung nursing diagnosis)

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
NURSING CARE PLAN 4: (paki-specify nalang dito yung nursing diagnosis)

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
NURSING CARE PLAN 5: Impaired skin integrity related to a surgical procedure as evidenced by a tear in the perineum area

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EXPECTED

DIAGNOSI EXPLANATIO S INTERVENTIONS OUTCOME
S N

Subjective: Impaired Skin is the After 3 1. Assess 1. To provide After 3 hours of

 Reports of skin primary hours of blood comparative nursing
itching integrity defense of nursing supply and baseline interventions,
 Pressure in related to the body; it intervention sensation and patient has:
affected/surrou a surgical protects the s, patient of skin opportunity
procedure body against will: surfaces for timely 1. Identified
nding area
as infections and 2. Provide intervention individual
 Numbness of evidenced diseases 1. Identify adequate 2. To prevent risk factors.
affected or by a tear brought about individual clothing or vasoconstri 2. Verbalized
surrounding in the by the risk covers. ction. relief from
area. perineum invasion of factors. 3. Perform 3. Systematic pain due to
area microbes in 2. Verbalize routine inspection the surgical
the body. A relief from skin can identify site.
Objective: pain due
normal skin is inspection developing
 Alteration in to the
Followed proper
moist and s, problems hygiene regimen.
skin integrity intact; surgical assessing and
(disruption of dryness of site. color, promotes
skin surface the skin is temperatur early
Follow proper
due to more prone e, surface intervention,
hygiene
episiotomy) to friction that regimen. changes, thus
may result to and reducing
impairment of texture. likelihood of
the skin 4. Maintain progression
integrity as and to skin
compared instruct in breakdown.
with a moist good skin To reduce risk
skin hygiene. of dermal
trauma,
improve
circulation, and
promote
comfort.
FDAR 1: (paki-specify nalang dito yung nursing diagnosis)

DATE TIME FOCUS NURSING PROGRESS NOTES

FDAR 2: Risk for profuse vaginal bleeding

DATE TIME FOCUS NURSING PROGRESS NOTES

6-2

07/22/19 8AM Risk for profuse vaginal D>received patient on bed. Awake, alert, and
bleeding coherent to time, place, and people.
>with presence of vaginal bleeding, categorized as
lochia rubra with an amount of 10-15mL vaginal
blood discharges.
>vital signs as follows:
Temp: 37
RR: 18 bpm
PR: 81 bpm
BP: 120/80

A>established therapeutic relationship

>provided health teachings to patient and SO(s)
about the signs and symptoms of profuse vaginal
bleeding
>assessed client’s lochia
>monitored vital signs

R>patient verbalized understanding of health

teachings
>manifested minimal amount of vaginal bleeding
FDAR 3: (paki-specify nalang dito yung nursing diagnosis)

DATE TIME FOCUS NURSING PROGRESS NOTES

FDAR 4: (paki-specify nalang dito yung nursing diagnosis)

DATE TIME FOCUS NURSING PROGRESS NOTES

FDAR 5: Impaired skin integrity

DATE TIME FOCUS NURSING PROGRESS NOTES

6-2

07/22/19 12PM Impaired skin integrity D> received patient on bed. Awake, alert, and
coherent to time, place, and people.
>with verbal reports of itching and numbness of the
affected area and surrounding area of the incision
site

A>established therapeutic relationship

>educated patient about individual risk factors
>provided health teachings about proper hygiene to
patient and SO(s)
>assessed incision site

R>patient identified individual risk factors

>patient verbalized understanding of the health
teachings about proper hygiene
>incision site manifested signs of inflammation