Data Nursing Diagnosis Scientific Rationale Objectives Intervention Rationale Evaluation
Data Nursing Diagnosis Scientific Rationale Objectives Intervention Rationale Evaluation
Data Nursing Diagnosis Scientific Rationale Objectives Intervention Rationale Evaluation
RATIONALE
OBJECTIVE: Risk for Infection Contamination of wound Short Term: -Monitor vital signs -An increase in After 3hrs of
38.5 °C related to blood loss surface with After 3hrs of nursing temperature, heart/ nursing
Hemoglobin: and invasive microorganism thus intervention, the patient cardiac rate and shortness intervention, the
65g/L procedures as a result these colonization has a will be able to have of breath are signs of patient had a
WBC: 29 x of postpartum complete new cells for stable vital signs and infection. temperature of
10^3 µ/l hemorrhage oxygen and nutrition able to verbalize 36.8 °C and
because their by- understanding of risk -Check the episiotomy site -These indicates localized verbalize that
products can interfere factors, identify and abdominal wound for infection requiring she understands
with a healthy surface interventions, and signs of edema, erythema, immediate intervention to the risk factors,
condition that leads to demonstrate techniques separation of wound edges, prevent systematic able to identify
infection. to prevent risk of purulent drainage. involvement. interventions
infection. and demonstrate
-Fundamentals Of techniques to
Nursing by Kozier page Long Term: prevent infection
910 The patient will be able such as proper
to achieve timely wound hygiene and
healing and continue to disposing of
be free of any symptoms contaminated
of infection during the pads, tissues,
postpartum period. - Observe for signs of fever, -These symptoms may etc.
chills, body malaise, reflect systematic
anorexia, pelvic pain or involvement and can lead Long Term:
uterine tenderness. to possible bacteremia, to The patient was
shock, and death. able to be free
from infection
showing stable
-Administer iron -Iron supplement corrects vital signs,
supplement as ordered. anemia and improves normal blood/
wound healing. lab results and
shows signs of
-Teach and demonstrate -To prevent the spread of wound healing.
proper handwashing and infections.
self-care techniques.
Review of handling and
disposing of contaminated
materials used.
DATA NURSING DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION
RATIONALE
OBJECTIVE: Deficient Fluid Volume Postpartum hemorrhage Short Term: -After 3 hours of
-Assess uterine
-Heavy vaginal related to postpartum is the excessive bleeding After 3 hours of nursing -To note how much blood nursing
contractions amd lochia
bleeding: lost hemorrhage following the delivery of intervention, the patient loss the patient is intervention, the
flow at least every 2 hours.
900ml of blood a baby. Hemorrhage will be able to have experiencing and prompt client’s cardiac
Keep perineal pads used
-Decreased urine may occur immediately decreased fluid volume for immediate intervention. rate is between
during bleeding and weigh
output: 10ml after birth or over several loss or will maintain fluid 70-100 beats per
-Cardiac Rate: 120- hours following delivery. volume at a functional to determine the amount of minute and
130 per minute Normally, the Uterus level as evidenced by blood loss, monitor the blood pressure
conracts after the adequate Hemoglobin, amount of blood loss is at 110/60
delivery of the placenta, Hematocrit, stable vital mmHg. Lochia
and these contractions signs, adequate urine has slowed to
help close the vessels output, good uterine -Changes in BP and moderate
-Monitor vital signs with
that supplied blood from contractility, and normal pulse/cardiac rate are amount of flow
emphasis on the Blood
mother to the baby. capillary refill time. estimates for blood loss. with no large
Pressure
When these contractions clots, uterus is
do not continue or not firm and
strong enough, hemoglobin level
hemorrhage occurs. -Monitor lab values such as -Both lab values determine is at 15 g/dL.
Long Term: hematocrit and hemoglobin the amount of blood loss -After 2 days of
After 2 days of nursing
count
intervention, the patient intervention,
-Maternity Nursing by will be able to - To make sure that no client is able to
-Place the client in a side
Lowdermilk, Chapter 25 understand the causative blood is pooling understand the
lying position to make sure
page 820 factors and purpose of underneath causative factors
that no blood is pooling
interventions and and purpose of
underneath.
medications to be given. the interventions
and medications
given. Patient is